Every finding on record at Sandstone of Tucson Rehab Centre

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of 1 resident (#1) to be free from verbal abuse by staff. The deficient practice could result in further abuse of residents and appropriate action not taken.Findings include:-Regarding Resident #1 (alleged victim):Resident #1 was admitted to the facility on [DATE], with diagnoses of hemiplegia, chronic kidney disease, Schizoaffective Disorder, Type 2 Diabetes Mellitus, Major Depressive Disorder, and dementia.The care plan revised on November 12, 2025, revealed that the resident was in a secured unit related to dementia with behavioral disturbance and had physical aggression towards staff. The care plan identified a behavior problem as evidenced by being verbal and physical aggression with staff and refusal of care from people of different ethnicities. The Care plan further identified that Resident #1 was at risk for altered mood state and impaired psychosocial well-being related to schizoaffective disorder, major depressive disorder, impulsivity, and periods of emotional dysregulation.The Care plan documented that Resident #1's mood could fluctuate with or without an identifiable trigger and could be exacerbated by overstimulation, particularly during personal care or other high-demand situations. During periods of distress, the resident could demonstrate ineffective communication, impulsive behaviors, difficulty maintaining positive interpersonal relationships with staff and peers. The Care plan interventions included cares in pairs, the staff to approach the resident in a calm, consistent, and non-threatening manner while minimizing environmental stimulation during care and other potentially stressful interactions, allow adequate time for processing, offer simple choices, and use clear, concise communication to reduce frustration and support effective expression of needs, monitor for changes in mood, impulsive behaviors, withdrawal, agitation, or other signs of psychiatric decompensation, promptly communicate significant changes to the interdisciplinary team and psychiatric provider, reinforce appropriate coping skills, provide positive redirection and reassurance as needed, encourage participation in preferred activities and social interactions as tolerated to promote psychosocial well-being, provide the resident with supportive care and services to promote a sense of safety, well-being and positive self-image, and if safe, allow the resident personal space. The annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental status (BIMS) score of 10, indicating moderate cognitive impairment. The assessment included that the resident exhibited physical and verbal behavioral symptoms and exhibited behaviors of rejection of care.A nursing progress note dated July 23, 2026, revealed that the resident was alert, compliant with his medications, and denied any pain or discomfort. Per the document, the resident had a behavior history of physical and verbal aggressions with care staff, the resident was verbally and physically aggressive during care with the certified nursing assistants (CNAs), and the resident was redirected but continued to be verbally and physically aggressive during care.A social services progress note dated July 23, 2026, revealed that the resident had an irritable mood and affect and was minimally engaged during interaction. Per the document, the resident did not recall the event related to the reported incident. -Regarding CNA (Staff #13 /alleged perpetrator):CNA (Staff #13) employee record revealed a:Hire date July 1, 2026No evidence of APS (Adult Protective Services) registry recordCertificate of Completion on Elder Justice Act and Preventing Abuse and NeglectCertificate of Completion for dementia careA written warning related to failure to appropriately de-escalate a resident interaction, for not meeting the facility's expectations for professionalism, customer service, and resident care. A facility 5-day investigation report dated July 27, 2026, revealed that the Behavioral Health Consultant (Staff #30) met with Resident #1 on July 22, 2026 and the Social Services met with Resident #1 on July 23, 2026. The resident did not recall the event. The report also revealed that CNA (Staff #7) and CNA (Staff #13) were interviewed. According to the facility's interview summary for Staff #7, Staff 13 requested Staff #7's assistance with placing sling under Resident #1. While the sling was being positioned, Resident #1 punched Staff #7 in the stomach. Staff #13 blocked Resident #1's fist from striking Staff #7. Resident #1 then grabbed Staff #13's hand and pulled it toward his chest. Staff #7 reported that Staff #13 was holding Resident #1's hand tightly while Staff #13 reported that Resident #1 was holding his hand tightly and would not let go. Staff #7 described a back and forth interaction between Resident #1 and Staff #13 throughout the care encounter. According to the facility's interview summary for Staff #13, Resident #1 attempted to punch Staff #7 in the stomach. Staff #13 blocked the punch, after which Resident #1 grabbed Staff #13's hand and squeezed it tightly. Staff #13 acknowledged saying, jokingly, stop being a sissy, in reference to how Resident #1 was squeezing his hand. Staff #13 further reported that Resident #1 told him, I hope you go to hell and Staff #13 responded, that's ok, it doesn't matter. Staff #13 stated he did not recall saying or doing that could have been misunderstood by Staff #7.The facility's interview summary further documented that while Staff #13 was later wheeling Resident #1 back to his room, Resident #1 attempted to strike Staff #13 in the face. Staff #13 reported that he blocked the resident's punch. Staff #13 acknowledged that he could have used better judgement and professionalism when communicating with Resident #1.The facility 5-day investigation concluded that the allegation of abuse was not verified. An interview was conducted on July 31, 2026, at 11:04 AM, with the Staff #13. Staff #13 stated that he and Staff #7 were in Resident #1's room to place a sling under the resident and the resident punched Staff #7. Staff #13 stated that he grabbed the resident's hand before the resident could throw another punch to Staff #7. Staff #13 stated it upset him when a man hits a woman. Staff #13 stated that the resident told him hope you die and he responded by saying okay and walked out of the resident's room. Staff #13 stated he was immediately contacted by management, was sent home and subsequently reassigned to another section. Staff #13 stated that he did not feel like he did something wrong, he said that he wanted to protect Staff #7, and he also said that he got in trouble for helping an employee for not getting hit. Staff #13 stated that abuse is hurting somebody and can be verbal. Staff #13 stated that he did not intend to say it to Resident #1, but it was seen as verbal abuse. Staff #13 further stated that he took care of Resident #1 several times, and sometimes the resident was nice and sometimes the resident was mean and when the resident acted mean, he would walk away. Further, Staff #13 stated that his dementia care training involved getting down to the residents' level to make them comfortable. Staff #13 also stated that if there was a resident with behavioral outburst, he would leave them alone, he would stand away from the resident so the resident would not get more mad. An attempt was made to conduct an interview with Resident #1 on July 31, 2026, at 1:44 PM. The resident had a visitor in his room. The visitor stated that she was the resident's family member, she was getting the resident down to sleep, she did not want the resident to be disturbed, and also stated for the surveyor to speak with the nurse.An interview was conducted on July 31, 2026, around 11:55 AM with a CNA (Staff #16). Staff #16 stated that Resident #1 can be pleasant, sometimes combative and it depends on how he feels. Staff #16 stated that, sometime last week, she instructed a CNA (Staff #7) to report an incident involving Resident #1 to the unit managers. An interview was conducted on July 31, 2026, at 12:03 PM with a Licensed Practical Nurse (LPN/Staff #43). The LPN stated that Resident #1 was one of their veterans, who cannot move his left arm, sometimes the resident might not be approachable, the resident used the F word, sometimes the resident might strike with his arm, the resident was in their locked unit for his behaviors, and the resident was not on any psychotropic medications. The LPN stated that Resident #1 needed to be changed, the CNA (Staff #7) was a new CNA and the other CNA (Staff #13) was rough, and he was sent home. The LPN stated that she assessed the resident and he did not have marks. An interview was conducted on July 31, 2026, at 12:45 PM with the Assistant Director of Nursing (ADON/Staff #15). The ADON stated that abuse is an act that is unwarranted to another individual and it could be financial, sexual, verbal and physical. The ADON stated that if she was made aware of any allegation of abuse, she would immediately notify the administrator/abuse coordinator. Regarding the incident involving Resident #1, the ADON stated that when the resident was being changed, the resident became combative so the CNAs (Staff #7 and Staff #13) had to deescalate the situation. The ADON stated that the resident was hitting and punching Staff #7 and Staff #13 attempted to deescalate by keeping the resident from hitting Staff #7 further. The ADON stated that Resident #1 was a veteran, and at baseline, he could be combative and verbally aggressive towards staff. The ADON stated that the resident's care plan included cares and pairs, making sure to take a calm approach, giving the resident space to calm down, and then re-approach. The ADON stated that their Human Resources department followed up on the Staff #7 who got punched by the resident and Staff #13 was removed from the floor pending investigation.A phone interview was conducted on July 31, 2026, at 12:54 PM with Staff #7. The CNA stated that abuse could be financial, physical, and verbal. The CNA stated that she was called by another Staff #13 to Resident #1's room to assist with the transfer lift, to get the resident up for dinner, and it happened on a Wednesday. The CNA stated that she was putting a sling under the resident and the resident started punching her. The CNA stated that she was shocked. The CNA stated that Staff #13 grabbed Resident #1's hand and pitted against his chest, assuming to stop the resident from hitting her. The CNA stated that Staff #13 started speaking to the resident by saying, fucking pussy, how dare you put hand on a woman, I should put my hands on you. The CNA stated that the resident said fuck you and hope you die. The CNA stated that Staff #13 said the same thing to the resident. The CNA stated that she went to another CNA and the CNA told her to speak with the supervisor. The CNA stated that she filled out a report after speaking with the supervisor. The CNA further stated that she considered the incident abuse on the resident. The CNA stated that the resident had a mental health problem. The CNA stated that Staff #13 was sent home.An interview was conducted with the Director of Nursing (DON/Staff #20) and present during the interview was Regional Nurse Consultant (Staff #35). The Regional Nurse Consultant stated that abuse is neglect, misappropriation, verbal, and the DON stated that abuse is also emotional. The Regional Nurse Consultant stated that verbal abuse is calling somebody asshole, and degrading them verbally. The Regional Nurse Consultant also included intimidation and physical abuse such as hitting, slapping, strangling, as examples of abuse. The Regional Nurse Consultant stated that in the dementia care unit, the residents have specific needs and it depends on their plan of care. The Regional Nurse Consultant stated that the process of deescalating involved safety first. The DON stated that deescalating involved providing space, but not stepping away from a resident on a sling during a transfer lift. Regarding Resident #1, the DON stated that the resident was being cared for by two CNAs (Staff #7 and Staff #13), the resident became combative at some point, and Staff #13 tried to block the resident from hitting Staff #7. The Regional Nurse Consultant stated that she did not ask for a visual on how Staff #13 blocked the resident from hitting Staff #7. The Regional Nurse Consultant stated that the plan of care for a resident in the dementia care unit would include deescalating, stepping away as long as it was safe to do so, switching staff, and re-approaching. The DON stated that she would look at the resident's plan of care to determine what to do to that specific resident. The DON stated that the impact of not stepping away from Resident #1 during his behavioral outburst could make the resident continue his outburst.An interview was conducted on July 31, 2026, at 1:24 PM with the Administrator (Staff #8). The Administrator stated that abuse is any type of physical, mental, financial, sexual, technical, and infliction on a resident. The Administrator stated that a physical abuse example would be hitting a resident and handling a resident roughly. The Administrator stated that a verbal abuse example would be swearing at a resident using foul language such as using the F word and belittling the resident using the stupid word. The Administrator stated that the process of providing care to residents in a behavioral unit included having a care plan that was individually tailored for each resident so the care can be provided appropriately, using cares in pairs requiring 2 staff member to provide care in repositioning the resident; during transferring the resident; or maybe due to resident being abusive to make sure that the resident and the staff remain safe, and due to residents making false allegations. The Administrator also stated that the process of deescalating a resident with a behavioral outburst included encouraging everyone to back away, ask the residents what they needed, and for the staff to wait until the resident calms down before the staff continue to engage with the care. Regarding Resident #1's incident, the Administrator stated that their Behavioral Consultant Nurse (Staff #30) interviewed the staff member involved in the incident. The Administrator stated that she did not consider Resident #1 incident abuse because the CNA (Staff #13) was trying to protect the other CNA (Staff #7) from Resident #1. The Administrator stated that the CNA (Staff #13) statement was that he did not strike or hold the resident. The Administrator stated that Staff #1 saw the incident differently, and stated that the Staff #13 was the one being held by Resident #1 by holding his hand. The Administrator stated that Staff #13 put his hand in between the other CNA (Staff #7) and Resident #1 and then Resident #1 squeezed Staff #13's hand. The Administrator also stated that Staff #13 said that it was more of a joking like interaction with Resident #1 when the Staff #13 said to quit squeezing his hand. The Administrator stated that Staff #13 and Resident #1 were bantering back and forth and that Staff #13 does that in a none abusing way but in a conversation that would distract Resident #1. An interview was conducted on July 31, 2026, at 1:48 PM with the Behavioral Health Consultant (Staff #30). The Behavioral Health Nurse Consultant stated that her responsibilities included assisting with training and consulting. The Behavioral Health Nurse Consultant stated that Resident #1 baseline behavior included being aggressive, striking at a staff, and his care plan intervention included 2 to 1 staff when providing care. The Behavioral Health Nurse Consultant stated that she interviewed Staff #13 and during the interview, Staff #13 described Resident #1 as aggressive, trying to strike at a female small CNA (Staff #7), Staff #13 blocked Staff #7 from getting punched, the resident grabbed the Staff #13 arm while he was trying to block Staff #7 from getting hit. The Behavioral Health Nurse Consultant stated that the CNA (Staff #13) jokingly deescalated the resident by saying don't be a sissy. The Behavioral Health Nurse Consultant stated that she would not say don't be a sissy to a resident because it is not a term she would use. The Behavioral Health Nurse Consultant stated that she would use other techniques to distract a resident during a conversation. The Behavioral Health Nurse Consultant stated that the impact of saying to a resident don't be a sissy would depend on the resident and the relationship between the CNA and the resident. The Behavioral Health Nurse Consultant stated that the resident used the F word often, and if the resident used the F word in front of her, she would just smile because she would not take it personally. The Behavioral Health Nurse Consultant stated that later on when the Staff #13 took Resident #1 back to his room by himself, the resident tried to strike Staff #13 face, which happened shortly after the incident. The Behavioral Health Nurse Consultant stated that she checked on the resident after Staff #13 was sent home. The Behavioral Health Nurse Consultant stated that she was present while Staff #7 was being interviewed by her manager, and she did not interview nor take CNA (Staff #7) statement.A review of the facility policy titled, Abuse and Neglect, with an adopted date of May 1, 2024, revealed that it is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. This includes but is not limited to freedom from any physical or chemical restraint not required to treat the resident's medical symptoms. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. Physical abuse includes but is not limited to infliction of injury that occurs other than by accidental means. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, roughly handling. Verbal abuse includes but is not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc.A review of the facility policy titled, Resident Rights, with an adopted date of May 1, 2024, revealed that it is the policy of the facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The Resident has the right:To be treated with consideration, respect, and full recognition of his or her dignity and individuality.To be free from verbal, sexual, mental or physical abuse, corporal punishment,involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience or for other than treating medical symptoms.A review of the facility policy titled, Care Planning, with an adopted date of May 1, 2024, revealed that it is the policy of the facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. A review of the facility policy titled, Care Planning - Baseline, with an adopted date of May 1, 2024, revealed that (3.) The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. (4.) The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to:The initial goals of the resident;A summary of the resident's medications and dietary instructions;Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; andAny updated information based on the details of the comprehensive care plan, as necessary.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to follow 1 resident (#1) care plan during a behavioral episode. The deficient practice could place the residents' safety at risk. Findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses of hemiplegia, chronic kidney disease, Schizoaffective Disorder, Type 2 Diabetes Mellitus, Major Depressive Disorder, and dementia. A care plan revised on November 12, 2025, revealed the following focus areas that included:Behavior problem as evidenced by being verbally and physically aggressive with staff and refusingcare from people of different ethnicities;Risk for altered mood state and impaired psychosocial well-being related to schizoaffective disorder, major depressive disorder, impulsivity, and periods of emotional dysregulation. His mood may fluctuate with or without an identifiable trigger and can be exacerbated by overstimulation, particularly during personal care or other high-demand situations. During periods of distress, the resident may demonstrate ineffective communication, impulsive behaviors, difficulty maintaining positive interpersonal relationships with staff and peers, and reduced ability to cope with environmental stressors. Interventions included:cares in pairs, staff to approach the resident in a calm, consistent, and non-threatening manner while minimizing environmental stimulation during care and other potentially stressful interactionsallow adequate time for processing, offer simple choices, and use clear, concise communication to reduce frustration and support effective expression of needs,provide positive redirection and reassurance as needed,provide the resident with supportive care and services to promote a sense of safety, well-being and positive self-image, and if safe, allow the resident personal space. A review of the annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental status (BIMS) score of 10, indicating cognitive moderate impairment. The assessment included that the resident exhibited physical and verbal behavioral symptoms and exhibited behaviors of rejection of care. A nursing progress note dated July 23, 2026, revealed that the resident was alert, compliant with his medications, and denied any pain or discomfort. Per the document, the resident had a behavior history of physical and verbal aggressions with care staff, the resident was verbally and physically aggressive during care with the certified nursing assistants (CNAs), and the resident was redirected but continued to be verbally and physically aggressive during care.A facility 5-day investigation report dated July 27, 2026, revealed that a Certified Nursing Assistant (CNA staff # 7) reported to the Assistant Director of Nursing (ADON/staff #15) that while she was assisting CNA (staff #13) transfer Resident #1, the resident punched her in the stomach and staff #13 held the resident's hand tightly and would not let go. The report included that CNA (staff#13) lightheartedly told the resident to stop being a sissy. The facility 5-day investigation report revealed a conclusion that the allegation of abuse was not verified. A facility 5-day investigation report dated July 27, 2026, revealed that the Behavioral Health Consultant (Staff #30) met with Resident #1 on July 22, 2026 and the Social Services met with Resident #1 on July 23, 2026. The resident did not recall the event. The report also revealed that CNA (Staff #7) and CNA (Staff #13) were interviewed. According to the facility's interview summary for Staff #7, Staff 13 requested Staff #7's assistance with placing sling under Resident #1. While the sling was being positioned, Resident #1 punched Staff #7 in the stomach. Staff #13 blocked Resident #1's fist from striking Staff #7. Resident #1 then grabbed Staff #13's hand and pulled it toward his chest. Staff #7 reported that Staff #13 was holding Resident #1's hand tightly while Staff #13 reported that Resident #1 was holding his hand tightly and would not let go. Staff #7 described a back and forth interaction between Resident #1 and Staff #13 throughout the care encounter. According to the facility's interview summary for Staff #13, Resident #1 attempted to punch Staff #7 in the stomach. Staff #13 blocked the punch, after which Resident #1 grabbed Staff #13's hand and squeezed it tightly. Staff #13 acknowledged saying, jokingly, stop being a sissy, in reference to how Resident #1 was squeezing his hand. Staff #13 further reported that Resident #1 told him, I hope you go to hell and Staff #13 responded, that's ok, it doesn't matter. Staff #13 stated he did not recall saying or doing that could have been misunderstood by Staff #7.The facility's interview summary further documented that while Staff #13 was later wheeling Resident #1 back to his room, Resident #1 attempted to strike Staff #13 in the face. Staff #13 reported that he blocked the resident's punch. Staff #13 acknowledged that he could have used better judgement and professionalism when communicating with Resident #1.Despite, Resident #1's comprehensive care plan interventions which included for the staff to approach the resident in a calm, consistent, and non-threatening manner while minimizing environmental stimulation during care and other potentially stressful interactions, allow adequate time for processing, offer simple choices, and use clear, concise communication to reduce frustration and support effective expression of needs, provide the resident with supportive care and services to promote a sense of safety, and if safe, allow the resident personal space, the incident on July 22, 2026, revealed that CNA (Staff #13) did not follow the resident's care plan interventions. Instead, per the 5-day investigation report dated July 27, 2026, the summary interview of Staff #7 revealed that Staff #7 believed that CNA (Staff #13) was holding Resident #1's hand tightly. Per the summary report, CNA (Staff #13) said jokingly, stop being a sissy, about how the resident was squeezing his hand. An interview was conducted on July 31, 2026, at 11:04 AM, with the CNA (CNA/Staff #13) who stated that his dementia care training involved getting down to the residents' level to make them comfortable. Staff #13 also stated that if there was a resident with behavioral outburst, he would leave them alone, he would stand away from the resident so the resident would not get more mad. An interview was conducted on July 31, 2026, at 12:03 PM with a Licensed Practical Nurse (LPN/Staff #43) who stated that Resident #1 needed to be changed, the CNA (Staff #7) was a new CNA and the other CNA (Staff #13) was rough, and he was sent home. The LPN stated that she assessed the resident and he did not have marks. An interview was conducted on July 31, 2026, at 12:45 PM with the Assistant Director of Nursing (ADON/Staff #15) who stated that the resident was being changed, the resident became combative so the CNAs (Staff #7 and Staff #13) had to deescalate the situation. The ADON stated that the resident was hitting and punching the CNA (Staff #7) and the other CNA (Staff #13) attempted to deescalate by keeping the resident from hitting the other CNA (Staff #7) further. The ADON stated that the resident's care plan included cares and pairs, making sure to take a calm approach, giving the resident space to calm down, and then re-approach. A phone interview was conducted on July 31, 2026, at 12:54 PM with a CNA (Staff #7). The CNA stated that abuse could be financial, physical, and verbal. The CNA stated that she was called by another CNA (Staff #13) to Resident #1's room to assist with the transfer lift, to get the resident up for dinner, and it happened on a Wednesday. The CNA stated that CNA (Staff #13) started speaking to the resident by saying fucking pussy, how dare you put hand on a woman, I should put my hands on you. The CNA stated that the resident said fuck you and hope you die. The CNA stated that the other CNA (Staff #13)) said the same thing to the resident.An interview was conducted with the Director of Nursing (DON/Staff #20) and present during the interview was Regional Nurse Consultant (Staff #35). The Regional Nurse Consultant stated that abuse is neglect, misappropriation, verbal, and that in the dementia care unit, the residents have specific needs and it depends on their plan of care and that the process of deescalating involved safety first. The DON stated that deescalating involved providing space, but not stepping away from a resident on a sling during a transfer lift. Regarding Resident #1, the DON stated that the resident was being cared for by two CNAs (Staff #7 and Staff #13), the resident became combative at some point, and one of the CNAs (Staff #13) tried to block the resident from hitting the other CNA (Staff #7). The Regional Nurse Consultant stated that the plan of care for a resident in the dementia care unit would include deescalating, stepping away as long as it was safe to do so, switching staff, and re-approaching. The DON stated that she would look at the resident's plan of care to determine what to do to that specific resident. The DON stated that the impact of not stepping away from Resident #1 during his behavioral outburst could make the resident continue his outburst. An interview was conducted on July 31, 2026, at 1:24 PM with the Administrator (Staff #8). The Administrator stated that abuse is any type of physical, mental, financial, sexual, technical, and infliction on a resident. The Administrator stated that a physical abuse example would be hitting a resident and handling a resident roughly. The Administrator stated that the process of providing care to residents in a behavioral unit included having a care plan that was individually tailored for each resident so the care can be provided appropriately, using cares in pairs requiring 2 staff member to provide care in repositioning the resident; during transferring the resident; or maybe due to resident being abusive to make sure that the resident and the staff remain safe, and due to residents making false allegations. The Administrator also stated that the process of deescalating a resident with a behavioral outburst included encouraging everyone to back away, ask the residents what they needed, and for the staff to wait until the resident calms down before the staff continue to engage with the care. Regarding Resident #1's incident, the Administrator stated that their Behavioral Consultant Nurse (Staff #30) interviewed the staff member involved in the incident. The Administrator stated that the process starts on admission with a baseline care plan, then the full care plan would be developed by each discipline and modified as changes in the resident's condition occur, as when events such as accusation of abuse occur, and the care plan would be updated quarterly and annually. The Administrator stated that the care plans should be followed to assure care was provided appropriately for the resident. The Administrator further stated that if a resident's care plan was not followed, the impact on the resident could potentially result in the resident receiving inappropriate care. An interview was conducted on July 31, 2026, at 1:48 PM with the Behavioral Health Consultant (Staff #30) who stated that the CNA (Staff #13) jokingly deescalated the resident by saying don't be a sissy. The Behavioral Health Nurse Consultant stated that she would not say don't be a sissy to a resident because it is not a term she would use, and that she would use other techniques to distract a resident during a conversation. The Behavioral Health Nurse Consultant stated that the resident used the F word often, and if the resident used the F word in front of her, she would just smile because she would not take it personally.A review of the facility policy titled, Care Planning, with an adopted date of May 1, 2024, revealed that it is the policy of the facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. A review of the facility policy titled, Care Planning - Baseline, with an adopted date of May 1, 2024, revealed that (1.) to assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of admission. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure an allegation of resident-to-resident abuse was reported to the applicable and required state agencies within 2 hours, for two of four sampled residents (#50 and #40). The deficient practice could result in an allegation of abuse not being reported and investigated in a timely manner, and could result in continued harm to residents.Findings include:Resident #50 was admitted to the facility on [DATE], with diagnoses of dementia, bipolar disorder, and heart failure.A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #50 had a Brief Interview for Mental Status (BIMS) assessment score of 7, indicating severe cognitive impairment.A Nursing Note dated May 4, 2026, at 3:43 p.m. revealed Resident #50 was observed with small discoloration / light bruising to her right outer arm. The note revealed Resident #50 stated she hit her arm on the door and was unable to recall further details regarding the injury.There was no evidence in Resident #50's medical record of documentation on May 4, 2026, regarding a resident-to-resident incident.A Nursing Note dated May 6, 2026, revealed that on May 4, 2026, at approximately 2:00 p.m., staff in Resident #50's room were assisting with the redirection of another resident during a wandering episode. The other resident was looking for a male whom he was calling by a specific name, who he thought was Resident #50. The other resident emotionally escalated and wanted to get Resident #50's attention and to get Resident #50 up out of bed. Staff continued to use verbal de-escalation and hand-on-hand redirection to distract the other resident to another object and guide the other resident out of Resident #50's room, which was ineffective. The note revealed that the other resident grabbed Resident #50's right arm and right leg while she was lying down in bed, and the other resident ended up halfway on Resident #50's bed while the other resident continued to attempt to get Resident #50's attention. Staff were able to intervene and separate the residents. The note revealed that Resident #50 was given reassurance, and that the wound nurse was in to do a skin check after the event. The nurse and the unit manager asked the resident how her bruise occurred, and Resident #50 stated that she hit it on the door. The note included that the local police responded that a report would not be completed because the police did not observe the incident.-Resident #40 was admitted to the facility on [DATE], with diagnoses of neurocognitive disorder with Lewy bodies, chronic heart disease, dementia, post-traumatic stress disorder, and acquired absence of right toe(s).An admission MDS assessment dated [DATE], revealed Resident #40 had no BIMS assessment completed due to the resident being rarely or never understood. Section E, Behavior, revealed Resident #40 had episodes of physical and verbal behavioral symptoms directed toward others, in addition to wandering behavior that occurred 1 to 3 days.A Nursing Note dated April 4, 2026, at 2:23 p.m., revealed Resident #40 was exit-seeking, combative with staff during redirection attempts, and entering other resident's rooms.Another Nursing Note dated May 4, 2026, at 3;12 p.m., revealed Resident #40 was agitated, exit-seeking, pacing the hallway and hit staff during attempts at redirection.There was no evidence of a progress note in Resident #40's medical record completed on May 4, 2026, regarding a resident-to-resident incident.A facility self-report submitted to the State Agency on May 5, 2026, at 11:44 a.m. revealed that on May 4, 2026, at approximately 2:00 p.m., a Behavioral Health Technician (BHT / Staff #41) was attempting to de-escalate Resident #40 in the hallway. The report revealed that a code grey was called, and that Resident #40 was yelling and cursing at the BHT and a Certified Nursing Assistant (CNA / Staff #83). The report revealed Resident #40 entered Resident #50's room while Resident #50 was lying in her bed, and yelled a specific male's name, grabbed Resident #50's arm and leg. The report included that Staff #41 and Staff #83 were able to get Resident #40 from the bed area, and Resident #40 sat on the floor. The report revealed that a head-to-toe assessment was completed for Resident #50, and a bruise was found on her right arm. Additionally, the report included that Resident #50 exhibited no sign of distress.A telephonic interview was conducted on May 7, 2026, at 11:08 a.m., with a CNA (Staff #83) who stated that on May 4, 2026, after Resident #40 had received wound care, he was very agitated and was walking around the unit. The CNA stated that the resident was calling a male's name and entered Resident #50's room, where Resident #50 was lying on her bed. The CNA stated that Resident #40 grabbed Resident #50's arm and leg and was trying to pull her off of the bed, before climbing on top of Resident #50 in the bed. The CNA stated that Resident #50 was very upset and was screaming and yelling because she did not know what was going on. The CNA stated that she then pulled Resident #40 off of Resident #50 and onto the floor.An interview was conducted with a BHT (Staff #41) on May 7, 2026, at 12:23 p.m., who stated that if there was an incident that could possibly be abuse, staff were expected to report the situation immediately to their direct supervisor and the administrator. The BHT stated that it would not be appropriate for a resident to grab another resident, and that it could possibly be considered a situation of abuse. The BHT stated on May 4, 2026, Resident #40 was agitated and wandering, and that Resident #40 pushed the BHT out of the way in the hallway as the BHT was attempting to provide redirection and de-escalation. The BHT stated that then, Resident #40 saw Resident #50 lying in her bed, and entered her room and yelled out a male's name as he grabbed Resident #50's right arm and right leg. The BHT stated that he worked together with the CNA, Staff #83, to get Resident #40 off of Resident #50, and that Resident #40 was assisted to the floor. The BHT stated that Resident #40 was surprised by the interaction, and asked the staff directly after the incident if there was any blood.A telephonic interview was conducted with the Assistant Director of Nursing (ADON / Staff #2) on May 7, 2026, at 1:22 p.m., who stated that on May 4, 2026, she heard the call for code grey and went to the unit to assist, and observed Resident #40 being assisted by staff into his wheelchair. When she asked the CNA (Staff #83) and the BHT (Staff #41) what happened, Staff #2 stated that she was informed that the staff were trying to redirect Resident #40, who entered Resident #50's room and had been trying to wake Resident #50 up and sat on Resident #50's bed. The ADON stated she did not draw any conclusions whether this was an instance of physical abuse, and that she reported the incident to the covering Administrator (Staff #7) right away.A telephonic interview was conducted on May 7, 2026, at 3:32 p.m. with the Administrator (Staff #5), who stated that she was away on vacation during the timeframe of the incident between Resident #50 and Resident #40, and that the covering Administrator for that timeframe was Staff #7. The Administrator stated that her expectation was that any allegation of possible abuse be reported in accordance with state and federal regulations, and that facility staff were mandated to report allegations of abuse to the State Agency, to Adult Protective Services (APS), and to the ombudsman within 2 hours. The Administrator stated that the importance of reporting in a timely manner was to protect residents from injury, to have staff suspended if necessary, and to protect residents from further abuse.An interview was conducted with the covering Administrator (Staff #7) on May 7, 2026, at 3:49 p.m. who stated that he was covering as Administrator during the timeframe of the incident between Resident #40 and Resident #50. Staff #7 stated that, to his knowledge, Resident #40 entered Resident #50's room, and was yelling out his old business partner's name and mistook Resident #50 for his old business partner. Staff #7 stated that Resident #40 then grabbed Resident #50's arm and leg and was attempting to wake her up when the BHT (Staff #41) and the CNA (Staff #83) separated the residents and got Resident #40 out of the room. Staff #7 stated that the incident occurred on May 4, 2026, around 2:00 p.m., and that the report to the State Agency occurred on May 5, 2026. Staff #7 stated that the reason he waited almost a day to report the incident to the State Agency was that there was no harm done to the residents.Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation, dated November 2027, revealed the facility will provide a safe resident environment and protect residents from abuse. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting and kicking. Physical abuse may be possible when a resident receives an injury that is suspicious because the source of the injury is not observed, the extent or location of the injury is unusual or because of the number of injuries either at a single point in time or over time. Regarding resident to resident abuse: cognitive impairment or mental disorder does not preclude a resident from being abusive. In determining abuse, willful (deliberate) action (not inadvertent or accidental) will be considered regardless of whether the individual intended to inflict injury or harm. The policy also revealed that each resident-to-resident altercation should be reviewed for potential abuse.Review of a facility policy titled, Resident Rights, dated May 1, 2024, revealed that it was the policy of the facility that all resident rights be followed per state and federal guidelines, as well as other regulatory agencies, and that residents had the right to be free from physical abuse.Review of the Code of Federal Regulation 42 CFR S 483.12, revealed that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Based on observation, interviews, and review of facility policy and procedure, the facility failed to ensure food was stored and prepared under sanitary conditions. The deficient practice could lead to pests in the kitchen and/or spread of infection to residents.Findings include:A blank kitchen Daily Cleaning Log revealed a list of tasks including Wash & Sanitize Prep Tables / Countertops, Wash & Sanitize Dining Room Tables, Sweep & Mop Kitchen Floor, and the log also included a blank space for staff responsible, and a check box for each day of the week.A blank Validation Checklist Kitchen Observation revealed to walk through the kitchen at the start and end of every shift. The document included a list of tasks that included Floor is clean and free of debris, Canned goods have an uncompromised seal, Bottom shelves throughout kitchen clean and sanitized, and no clutter on Bottom shelves throughout. The log included a check box for each day of the week.A formal request was submitted to the facility on May 7, 2026, for a kitchen cleaning log form, and any kitchen cleaning logs completed in the past three months. The facility provided a signed statement that for the past three months there were no completed cleaning logs.An interview was conducted with a certified nursing assistant (CNA / Staff #25) on May 6, 2026, at 10:54 a.m. who stated that she has seen an ongoing issue of lack of cleanliness coming from the kitchen. Staff #25 stated that often, she would notice that dishes such as cups coming from the kitchen as clean would have grease residue in them, and that often as she poured juice out of pitchers for residents, that she could see dirt or residue on the bottom of the inside of the pitchers. Staff #25 stated that when she noticed this, she returned the dirty dishes to the kitchen to get new ones. Additionally, Staff #25 stated that in one instance, she started to pass meal trays to residents from the meal cart that was just delivered to her hallway, and that there was an old used meal tray on the cart from a resident from a previous meal that was left on the cart with the other new meal trays that were to be delivered, and that she was concerned of the cleanliness issue for residents.An observation was conducted of the kitchen with the Dietary Manager (Staff #66) on May 6, 2026, at 11:43 p.m., who had arrived to the facility at that time to unlock the kitchen area. There were no staff working in the kitchen at that time of night. The kitchen observation revealed an area with storage racks of clean pots and pans. Underneath the pots and pans rack was a puddle of standing water approximately 2 feet long and 1 foot wide, with the puddle extending along the wall of the area. The wall was observed to function as the exterior wall of the facility on the other side. There was no sink or dishwasher or faucet anywhere in the direct vicinity of the puddle. The nearest sink was approximately 10 feet away, and there was no trail of water leading to the puddle. Additionally, the pots and pans observed on the rack were completely dry.An interview was conducted with Staff #66 at that time, who stated that when it rains heavily, water leaks into the kitchen, and that it has been an ongoing issue since he started working at the facility in November 2025. Staff #66 stated that the water was coming from behind the wall, and that it had last rained about a day and a half ago. Staff #66 stated that maintenance staff had already been alerted and were aware of the issue from before he started working at the facility. Staff #66 declined to state whether there would be any risk from water leaking from behind a wall.The observation of the kitchen continued in the dry goods storage area and at approximately 11:50 p.m., a puddle of sticky-appearing, clear, yellowish residue was observed on the floor underneath a rack of canned food. It was observed to have dripped down from a large can of fruit that had juice residue on the label of the canned fruit. There were also spattered juice residue drops on the rack, the wheel of the rack, and spattered drops surrounding the puddle of juice residue on the floor.Another interview was conducted at that time with Staff #66, who stated that the residue was coming from a damaged can of tropical fruit, and Staff #66 then picked up the can and disposed of it.Another observation of the kitchen was conducted on May 7, 2026, at 11:42 a.m., with Staff #66 in the dry goods storage area. In the same area where the juice residue was observed from the leaking can of tropical fruit from the previous evening, there was observed residual dried, sticky-appearing droplets on the floor. Additionally, there were marks on the floor that indicated some of the residue had been wiped up and smeared; however, there was still sticky appearing juice residue on and around the wheel of the rack, and still some remaining droplets on the floor.An interview was conducted with Staff #66 at that time, who stated the residue on the floor was from the leaking can of fruit from the previous evening, and that he cleaned up the mess, but that he had missed some. When Staff #66 was asked if he had any kitchen cleaning logs, Staff #66 showed a copy of a blank Validation Checklist Kitchen Observation, and stated that he had none that were completed. Staff #66 stated that the facility's process for ensuring the kitchen is cleaned was that a lot of the kitchen staff have worked at the facility for years and that they know to clean the kitchen if it gets dirty. Staff #66 stated that usually staff clean the kitchen after every meal, and that additional cleaning is done after the dinner meal in the evening. Regarding the water puddle under the pots and pans storage rack from the previous evening, Staff #66 stated that he had talked to maintenance staff this morning and that the maintenance staff said it was an ongoing issue and that it is not a quick fix.An interview was conducted with the Maintenance Director (Staff #11) on May 7, 2026, at 12:00 p.m. who stated he had received a work order this morning to address the water puddle under the pots and pans storage rack from the previous evening. Staff #11 stated that he believed the water was coming from a sink that was approximately 10 feet away from the puddle area, and that he had fixed the issue this morning. Additionally, Staff #11 stated that staff had not informed him of any water puddles in the kitchen or leaks from the sink prior to this morning. Staff #11 also stated that the water puddle could have come from drips of water coming from pots and pans that staff had put away on the rack while still wet. Staff #11 declined to state whether it would meet his expectation for kitchen staff to leave a standing puddle of water on the floor of the kitchen through the night.A telephonic interview was conducted with the Administrator (Staff #5) on May 6, 2026, at 11:14 a.m., who stated that the kitchen staff have a process to ensure the kitchen is kept clean and that food is prepared under sanitary conditions. The Administrator stated the process included that staff should be wiping down counters, cleaning the floor routinely, sanitizing dishes, waiting until dishes are dry before putting them away, emptying used cleaning buckets, checking the sanitizing chemicals to ensure they are at the right level, ensuring used rags are cleaned, and cleaning meal carts between meals. Staff #5 stated that Staff #66 was responsible for ensuring the kitchen was kept clean and food was stored and prepared under sanitary conditions, and that she believed he kept cleaning logs to ensure cleanliness. Staff #5 stated that it would not meet her expectation for the kitchen to have food residue or spilled food left overnight in the kitchen, and that she would expect it were cleaned after the meal. Staff #5 stated that spills or food residue left overnight could pose a risk for infection control issues and pests in the kitchen.Review of the facility policy titled Food and Nutrition Services, dated July, 2018, revealed the facility will store, prepare, and serve food in a manner to minimize the potential for biological contamination and taking into consideration factors which may influence the growth of bacteria. Additionally, the facility will adhere to practices to minimize the potential of physical contamination of food. Dry foods and goods will be handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. Dry foods will be stored in closed containers and supplies will be rotated.Review of the facility policy titled Water Supply - Disruption Due to Repairs or Emergencies, dated May 2024, revealed in the event of sewage system flooding or failure, the facility will evaluate infection control risks to the residents and implement appropriate measures including possible transfer of residents as needed, and in accordance with current CDC/HICPAC guidelines and state and local health department requirements. Regardless of the original source of water damage (e.g., flooding, water leaks), wet, absorbent, structural items (e.g., carpeting, wallpaper, wallboard) and cloth furnishings will be assessed for possible replacement if they are not thoroughly dried within 72 hours and are considered to present continuing sources of contamination.Review of the facility policy titled Sanitation - Dietary Services, dated May 2024, revealed it is the policy of the facility that food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate for one of four sampled residents (#20) regarding a fall. The deficient practice could result in care team members not being fully aware of a resident's condition and could cause missed care and treatment.Findings include:Resident #20 was originally admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dementia, anemia, difficulty in walking, and anxiety disorder.A care plan focus initiated on October 21, 2018, revealed that Resident #20 was at risk for falls due to dementia causing confusion, poor safety awareness, incontinence, and hemiplegia to the right dominant side. There was no evidence of revisions or additions to the care plan focus following a fall incident on April 24, 2026.Another care plan focus initiated on October 21, 2018, revealed Resident #20 had an ADL self-care performance deficit with decreased mobility, weakness, and hemiplegia of right dominant side. The focus revealed an intervention initiated on December 15, 2025, that included assistance of 1 staff member for bathing and showering. The intervention was revised on April 27, 2026, to include 2 staff for bathing and showering.A quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) assessment score of 0, indicating severe cognitive impairment. Additionally, Section J revealed the resident had 1 fall since admission, reentry, or prior assessment.A nurse's note dated April 24, 2026, at 4:12 a.m. revealed the resident was alert and compliant with care and medications. The note included that the resident took his scheduled shower and no new skin issues were observed, and that the resident was seen lying in bed with respirations even and unlabored.An Alert Note dated April 24, 2026, at 4:45 a.m. revealed bathing had not been completed, and additionally, that the resident took his scheduled shower during the night shift. The note revealed no information about a fall.An incident report dated April 24, 2026, at 5:00 a.m. revealed that the Registered Nurse (RN / Staff #79) was called by the certified nursing assistant (CNA) in the shower room. As per the CNA, the resident leaned forward and hit his head on the shower handlebar while the CNA was busy putting shampoo on the towel. The report revealed that the resident sustained a cut (about 4 cm) and 1 cm deep on his right forehead. Immediate pressure was put on the resident's cut to stop the bleeding, a neuro check was done, and vital signs were taken, and were within normal limits. The report also included that the resident was unable to describe the incident. Additionally, the report revealed there were no predisposing environmental or physiological factors contributing to the cause of the incident; however, predisposing situational factors revealed that the CNA was busy putting shampoo on the towel. The documentation revealed that the on-call provider was immediately notified, and included the time of notification as April 24, 2026, at 7:00 a.m. (approximately 2 hours after the incident), and that the physician ordered the resident to be sent to the hospital for further evaluation and treatment.A physician's order dated April 24, 2026, at 5:45 a.m. included the resident may be to the hospital for further evaluation and treatment.A nurse's note dated April 24, 2026, at 6:47 a.m. revealed that the nurse (Staff #79) was called by the CNA in the shower room. The note also revealed that, according to the CNA, resident leaned forward and hit his head on the shower handlebar while the CNA was busy putting shampoo on the towel. The note revealed the resident sustained a cut (about 4 cm) and 1 cm deep on his right forehead, and that immediate pressure was put on the resident's cut to stop the bleeding, a neuro check was done, and vital signs were taken and were within normal limits. The documentation included that the on-call provider was immediately notified and ordered the resident to be sent to the hospital for further evaluation and treatment.There was no evidence of a fall incident or completion of a head-to -toe assessment.A Nurse Practitioner Progress Note dated April 24, 2026, at 2:47 p.m. revealed that Resident #20 had an accident in the shower this morning and had fallen forward and hit his head on the shower bar, which caused a large gash on his forehead. The note revealed that the resident was sent to the hospital emergency department for possible sutures, and the resident was still at the hospital.A hospital History and Physical Note dated April 24, 2026, revealed that the resident presented to the hospital after a ground-level mechanical fall while taking a shower. The note included that Resident #20 hit his head and suffered right facial laceration and hematoma, and additionally that x-rays revealed an acute right hip fracture.A hospital physician's progress note dated April 25, 2026, revealed that Resident #20 presented after a mechanical ground-level fall with a head strike, and that the exam revealed right hip tenderness. The note revealed that imaging was significant for right femur trochanteric fracture, and that the resident was to undergo an operation for a right hip intramedullary nailing procedure.A nurse's note dated April 27, 2026, revealed the resident was re-admitted to the facility after hospitalization for diagnoses of right forehead laceration and right hip fracture.An insurance provider Registered Nurse (RN) Follow-Up note dated May 4, 2026, revealed that Resident #20 had a recent fall with a right femur fracture, and a healed laceration to the right side of the forehead from the same incident.A written statement provided May 7, 2026, by the Director of Nursing (DON / Staff #90), revealed that the DON spoke to Staff #20 on April 28, 2026, at 2:34 a.m. to get his statement regarding the incident on April 24, 2026, when Resident #20 was sent to the hospital. The statement revealed that Staff #20 stated that during the shower, while Staff #20 was soaping up the washcloth, the resident tipped forward and hit his head on the bar of the shower, and that as the resident's head and knees were against the bar and wall, Staff #20 was able to catch the resident's body and the chair to prevent the resident from contacting the ground. The statement also revealed that Staff #20 was emphatic that no part of the resident ever touched the ground.An interview was conducted with a Licensed Practical Nurse (LPN / Staff #37) on May 7, 2026, at 9:39 a.m., who stated that she came to the facility in the morning just after the fall incident occurred on April 24, 2026. Staff #37 stated that she was told through report that Resident #20 was in the shower with a CNA, when the resident lurched forward quickly, and that the resident fell out of the shower chair and sustained a right hip fracture and had to have surgery. Staff #37 stated that normally, before the fall incident, Resident #20 had poor safety awareness, very bad vision, and behaviors of leaning forward suddenly.A telephonic interview was conducted on May 7, 2026, at 2:29 p.m. with a CNA (Staff #20) who stated that he was the staff member who was showering Resident #20 when the fall incident occurred on April 24, 2026, and that there was nobody else present in the shower room. Staff #20 stated that Resident #20 cannot see very well and has impulsive behaviors. Staff #20 stated that Resident #20 was seated in a shower chair in the shower stall, and that the brakes of the shower chair were locked. Staff #20 stated he turned slightly to put soap on a washrag, and he saw out of his peripheral vision that Resident #20 quickly reached for the water hose of the shower. Staff #20 stated that when the resident reached forward suddenly, the shower chair quickly tipped forward, the resident fell forward, the resident's face hit the wall, and the resident's knees hit the floor. Staff #20 stated that the shower chair was positioned behind the resident's backside and on top of the resident. Staff #20 stated that as the resident fell forward, Staff #20 reached his arm out to try to catch the resident, and when the resident hit the wall with his head and the floor with his knees, that Staff #20's arm was under the resident's chest and abdomen area. Staff #20 then stated he put his other arm behind the shower chair and with his arm on the resident's chest and his other arm behind the shower chair, Staff #20 lifted the resident along with the shower chair back upright into a sitting position. Staff #20 was asked to repeat whether the resident hit the floor when he fell, and Staff #20 reiterated that the resident did fall to the floor with his knees contacting the floor and his face against the wall of the shower. Staff #20 stated that after he assisted the resident back to sitting in the shower chair, he called out for the nurse (Staff #79), who came to the shower room and assessed the resident, who was bleeding from his forehead at that time. Staff #20 stated that he repeated exactly what happened, including that the resident contacted the floor with his knees, to the nurse (Staff # 79), and to management when they asked him about the incident.An interview was conducted with the Director of Nursing (DON / Staff #90) on May 7, 2026, at approximately 3:00 p.m., who stated that if a fall or accident were to occur to a resident, a CNA would be expected to notify the nurse right away to assess the resident. Staff #90 stated that the nurse would be expected to perform a complete head-to-toe assessment of the resident, and that the incident and assessment would be documented in the clinical record. Staff #90 stated that she was involved in investigating the incident regarding Resident #20 and that initially, she had received information that the resident had tipped forward in the shower chair and hit his head on the bar in the shower, and then later had received information from the hospital that Resident #20 had sustained a hip fracture. The DON stated that based on the information she received, the resident never hit the floor.A telephonic interview was conducted with an RN (Staff #79) on May 7, 2026, at 4:06 p.m., who stated that he was the nurse on duty at the time of Resident #20's shower incident on April 24, 2026. Staff #79 stated that he was preparing morning medications when Staff #20 notified him of an incident, and that the RN went to assess the resident. Staff #79 stated that Resident #20 was sitting in the shower chair and had an obvious head injury with a cut on the right side of his forehead that was bleeding. Staff #79 stated that Staff #20 told him that the resident leaned forward and was falling off the shower chair, and that the CNA was trying to explain to him what happened, but that Staff #20 was concerned and focused on what was going on with the resident's head. Staff #79 stated that Staff #20 did not tell him that the resident contacted the ground. Staff #79 stated he did not do a full head-to-toe assessment of the resident's body because he was focused on the resident's head injury. Staff #79 stated that he immediately called the provider and was ordered to send the resident to the hospital. Staff #79 stated he later found out the resident had a hip fracture from the incident.A telephonic interview was conducted with the Administrator (Staff #5) on May 7, 2026, at 3:32 p.m., who stated that her expectation for staff to document a fall or accident involving a resident would be to follow the facility's guidelines on documentation, and that staff would complete an incident report and progress note, and any following neuro checks. The administrator stated that if an incident or accident were not documented accurately, that something could be missed. Regarding the incident with Resident #20 in the shower, the Administrator stated that to her knowledge, the resident never hit the floor.Review of the facility policy titled Change in a Resident's Condition or Status, dated May 1, 2024, revealed that the nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident, a significant change in the resident's condition, or a need to transfer the resident to a hospital. The policy also revealed that prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information to the provider. The nurse will record in the resident's medical record information relative to changes in the resident's medical / mental condition or status.Review of the facility policy titled Charting and Documentation, dated May 1, 2024, revealed that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information is to be documented in the resident medical record: objective observations, medications administered, treatments or services performed, changes in the resident's condition, events, incidents or accidents involving the resident, and progress toward or changes in the care plan goals and objectives. The policy also revealed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of two of four sampled residents (Residents #16, #45) to be free from abuse by another resident (#26 and #121). The universe was 117. The deficient practice could lead to additional resident-to-resident altercations, creating an unsafe environment.Findings Include: -Regarding Resident #45 and Resident #121 A facility-reported incident form dated March 31, 2026, revealed that Resident #121 stated that she overheard Resident #45 speaking to someone on the phone and was speaking negatively of the facility, and called Resident #121 a bad name. The report included that Resident #121 proceeded to get out of her bed and went over to Resident #45, and said 'What did you say about me?' Resident #121 said Resident #45 made a slapping motion towards her, Resident #121 blocked the motion, and then Resident #121 grabbed Resident #45's wrist and struck Resident #45 with a closed fist on the cranial/facial area. The Report revealed a statement from Resident #45 who reported that she was on the phone 'complaining,' but she did not recall calling Resident #121 a 'bad name'. The Incident Report continued, revealing that Resident #45 acknowledged that Resident #121 made physical contact but was unable to recall additional details or to identify what precipitated the event, even with prompting. The report included that the allegation was verified by evidence collected during the investigation. -Resident #45 Resident #45 (alleged victim) was initially admitted on [DATE], and re-admitted on [DATE], with the diagnosis that included major depressive disorder, vascular dementia, psychotic disturbance, mood disturbance, anxiety, and unspecified symptoms and signs involving cognitive functions and awareness. A care plan focus related the following: Initiated on August 12, 2024: May present in a problematic manner, in which the resident's actions were characterized by ineffective coping skills; in relation to anxiety and agitation, as evidenced by pulling out her hair. The care plan revealed interventions that included not invading the personal space of Resident #45. Initiated on February 26, 2026: Resident utilizes antidepressant medication related to depression, as evidenced by self-isolation, with interventions to provide calm reassurance and empathy. A quarterly MDS (minimum data set) assessment dated [DATE], revealed that a BIMS (brief interview of mental status) score of 05, which indicated severe cognitive impairment at the time of the assessment. An March 10, 2026, provider order was written for one 125 mg sertraline HCl tablet one time a day for depression, as evidenced by isolation and poverty of speech. A nursing progress note dated March 26, 2026, revealed that at approximately 6:50 PM, staff heard a resident yelling out and, upon entering the room, the nurse found Resident #45 lying on the floor next to her bed with blood on her face. Another resident was found standing near her bed. The other resident was redirected out of the room and placed on 1:1 monitoring. The nurse assessed Resident #45 and found 2 hematomas on the back of the head, a small laceration approx. 0.5 cm by 0.2 cm by 0.1 cm to the right of the face, in between the upper lip and lower nose, and the nose bleeding. The note revealed that Resident #45 reported nothing occurring before the incident, and the other resident (#121) walked up to Resident #45 while she was sitting on her bed and pulled her hair, causing Resident #45 to slide to the floor, and that Resident #121 hit Resident #45 in the face several times. The note further revealed that Resident #45 was assisted to sit on the edge of her bed, her face was cleaned, and emotional support was provided. The note relayed that orders were received for laboratory testing, urinalysis, psychiatric evaluation, and that Resident #45 was sent to the emergency department for imaging. A skin assessment dated [DATE], revealed that the resident had been assessed with a bump on the left side and on the right side of her head with a cut approximately 1 cm in length on the right side of resident's upper lip. The assessment also revealed that the resident stated that there had been an altercation with another resident. An order dated March 26, 2026, was received to send the resident to the hospital for further evaluation. An order dated March 26, 2026, from the provider for change of condition monitoring for three days following an altercation. A neurological evaluation flow sheet dated March 26, 2027 through March 27, 2026, revealed that the resident had been evaluated every fifteen minutes for the first two hours after the initial evaluation, then every thirty minutes after the first two hours. The evaluation flow sheet also revealed that Resident #45 had been sent out to the emergency department after the first four hours, and evaluations resumed after the first eight hours of the initial evaluation. An emergency room report dated March 27, 2026, revealed Resident #45 had been brought in by ambulance after being assaulted by another resident. The report also revealed that no signs of a serious problem were evident, which would require an extended hospital stay. The report also revealed the presence of a small 5 mm shallow abrasion of the upper lip, not involving the [NAME] border, and otherwise atraumatic. The report also revealed mild tenderness of the left knee without any overlying skin changes or palpable effusion. A CT (Computed Tomography) scan report of the head and brain without contrast for assault, dated March 27, 2026, revealed no acute intracranial abnormality and noted to be within the limits of motion degradation. A CT scan report of the cervical spine without contrast for assault, dated March 27, 2026, revealed no acute fracture or traumatic malalignment of the cervical spine. An X-ray (x-radiation) report of the chest for assault, dated March 27, 2026, revealed no displaced rib fracture identified. An X-ray report of the left knee for assault, dated March 27, 2026, revealed mild soft tissue edema about the knee, and no acute fracture or dislocation of the left knee. -Resident #121: Resident #121 was admitted to the facility on [DATE], with the diagnosis that included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; major depressive disorder, recurrent, unspecified. An order dated November 28, 2025, revealed Resident #121 required behavior tracking related to intrusive behaviors crossing other residents' boundaries and wandering. A quarterly MDS assessment dated [DATE], revealed a BIMS score of 07, which indicated severe cognitive impairment at the time of the assessment. The assessment revealed no evidence of behavioral symptoms present at the time of the assessment. A progress note dated March 26, 2026, revealed that at approximately 6:50 PM, staff heard a resident yelling out and, upon entering the room, the nurse found another resident lying on the floor next to her bed with blood on her face. Resident #121 was standing near her bed. Resident #121 was redirected out of the room and immediately placed on 1:1 monitoring. The progress note relayed that Resident #121 stated that her roommate (Resident #45) accused her of cheating with her roommate's husband, then proceeded to hit her roommate (Resident #45) in the face several times. The note reported that an assigned sitter escorted Resident #121 to a new room assignment, and orders were received for laboratory testing, urinalysis, and psychiatric evaluation. Provider orders for Change of condition monitoring for three days following an altercation and a room move were ordered on March 26, 2026. A skin assessment dated [DATE], revealed that Resident #121 had been assessed with no new skin issues. A behavior note dated March 26, 2026, revealed that Resident #121 reported hitting Resident #45. A care plan focus with the initiation date of March 31, 2026, revealed the following focus areas: Behavioral disturbances, which included but are not limited to intrusive behaviors, poor boundaries, pacing, delusional thoughts, physical aggression related to dementia, major depressive disorder, and poor impulse control. The care plan focus also revealed that Resident #121 had an altercation with a peer on March 26, 2026. On March 31, 2026, at 11:00 AM, an interview was conducted with Resident #45. Resident #45 stated that her previous roommate had pulled her and had hit her face. Resident #45 also stated that she ended up on the ground and bled on her face. Resident #45 also stated that she had gone to the hospital after the incident and came back the next day. Resident #45 stated she had some facial pain, but has medications for any pain she may be experiencing. Resident #45 stated feeling safe at the time of the interview and glad she had not interacted with the resident since the altercation. On April 2, 2026, at 9:33 AM, an interview was attempted with Resident #121; however, Resident #121 is Spanish-speaking only, and there had not been any Staff on the hall at the time of the interview to assist with interpretive assistance. However, when asked about a previous roommate, the name of Resident #45 prompted Resident #121 was observed to scrunch of her nose and shaking her head no, while swatting at the air in front of her. No additional interview attempts were made with Resident #121. On April 2, 2026, at 9:36 AM, an interview was conducted with a CNA (Staff #91), who stated that she was made aware of the resident-to-resident altercation between Resident #45 and #121, and that Resident #45 stated something had provoked Resident #121 before the physical contact. The CNA stated that she had been privy to both Residents #45 and #121, and stated that the day before, March 25, 2026, Resident #45 expressed paranoid thoughts regarding staff and residents attempting to poison her, and that paranoid behaviors were Resident #45's baseline. Staff #91 also stated that there had not been any skin conditions observed on Resident #45, and that the skin conditions observed on Resident #45 on March 26, 2026, had to have been a direct result of the resident-to-resident altercation. On April 2, 2026, at 9:40 AM, an interview was conducted with another CNA (Staff #150), who stated that a nurse overheard yelling coming from the shared room of Residents # 45 and #121, Resident #121 was observed in the middle of the hallway in front of her room with blood on her right fist. The CNA stated that she was asked to speak to the residents and translate what happened in the room and that Resident #121 reported that Resident #45 had been speaking to Resident #121 about the husband of Resident #45, so she proceeded to hit Resident #45. The CNA stated that she observed Resident #45 on the ground with a bloody face, and when asked, Resident #45 reported that Resident #121 hit her in the face and pulled her hair. The CNA relayed that she could not believe what she witnessed. The CNA further stated that Resident #45 had a bloody nose and lip, a couple of bumps on her head and that and that Resident #45 was crying. On April 2, 2026, at 10:21 AM, a telephone interview was attempted with the RN on shift (Staff #138); it was unsuccessful. On April 2, 2026, at 10:43 AM, an interview was conducted with the Nurse Consultant (Staff #13). The Nurse Consultant also stated that for resident-to-resident altercations, staff is expected to separate the residents to ensure their safety. Staff #13 also stated that once everyone is separated from the situation, then she would tell the nurse supervisor and the abuse coordinator, who is the administrator. Staff #13 further stated that it was reported to her that Resident #121 struck Resident #45 in the face with a closed fist and pulled her hair. Staff #13 further stated that Resident #45 lost her balance during the altercation and fell to the floor. The Nurse Consultant further stated that Resident #45 had been assessed with a small laceration above her lip, just under her nose, and had been observed with a bloody nose and two hematomas next to each other on the head of Resident #45, and was sent to the hospital for evaluation of the hematomas. Staff #13 stated that within her role, she provided emotional support to both Residents #45 and #121, assisted with the move of rooms for Resident #121, provided interview assistance to staff and residents, notified the family and power of attorneys as applicable, and ensured the risk management assessments for the residents were completed. On April 2, 2026, at 11:44 AM, a joint interview with the Director of Nursing (DON/Staff #200) and the Administrator (Staff #166) was conducted. The Administrator stated that at approximately 6:50 PM, one of the nurses heard a resident yelling in the shared room, and upon entry, observed Resident #45 on the floor. A CNA was called in to assist with determining what happened, and obtained information that a physical altercation took place. The interpretation provided was that Resident #121 stated Resident #45 yelled at her and accused her of cheating with the husband of Resident #45, and Resident #121 stated she physically assaulted Resident #45, which caused Resident #45 to lose her balance and fall to the floor. The Administrator stated that Resident #121 was removed from the room and put with a 1:1 sitter, and Resident #45 was assessed, provided medical treatment, administered pain medication was assisted to her bed. The Administrator further stated that Resident #45 had a scrape under her nose, and per a physical assessment, she had two bumps on her head, which led to the decision to send her to the hospital for further medical attention. The Administrator further stated that the determination of the of abuse between Resident #45 and #121 was verified. -Regarding Resident #16 and Resident #26 Review of the facility's investigation report dated March 31, 2026, revealed that resident #16 was interviewed by the Social Service (SS/staff #127), and reported that resident #26 started hitting her for no reason and stated, she hit me twice on the arm, you can see the bruises. The resident further reported that the other resident started to cuss me out. Staff #127 asked for specific details and direct quotes, but the resident was not able to provide them. The resident was also not able to recall events verbatim and required redirection to remain focused on the interview. The investigation also included a Social Service's (SS/staff #127) interview with the alleged perpetrator (Resident #26), who stated that she was in the hallway when the other resident approached her and began being rude. Social Services reported that Resident #26 was not able to provide direct quotes, but stated that Resident #16 told her to Shut the F--k up. The Social Services interview included that Resident #26 denied any physical contact or altercation with Resident #16, stating that there was no hitting and that the other resident, and that was all she could recall of the incident. Additional review of the facility's investigation revealed that Licensed Practical Nurse (LPN, Staff #35) witnessed the incident and stated that on March 31, 2026, at 12:10 PM, stating that Resident #16 approached Resident #26 and yelled, get out of the way which startled Resident #26, who reacted by saying Fuck loudly and extending her left leg up, making brief contact with Resident #16's right forearm. The LPN intervened at the same time as this was occurring, immediately separating residents and assisting resident #16 to the front of the hall. -Regarding Resident #26: Resident #26 (alleged perpetrator) was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, major depressive disorder, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and epileptic seizures. The care plan revealed the following areas of focus: Used psychotropic medications related to behavior management secondary to diagnosis of schizoaffective disorder as evidenced by verbal/physical aggression, revised January 22, 2025. Interventions included to monitor/record occurrence of target behavior symptoms and document per facility protocol, revised January 18, 2020. Psychosocial wellbeing, revised on March 27, 2025, indicated that the resident had the potential to be physically aggressive related to a history of physical harm to others. Interventions initiated on November 27, 2019, included to monitor/document/report PRN any signs symptoms of resident posing danger to self and others; When the resident becomes agitated to intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. A behavior problem, including but not limited to (yelling/screaming/cursing at staff and peers, will often have outbursts unprompted), call light abuse, non-compliance with care and treatment, and instigating behaviors. The resident was noted to refuse alternate activities, care, would kick, hit, pinch, scratch, spit, bite, and use abusive language targeting both residents and staff, revised September 5, 2025. Interventions revised on January 23, 2026 included that the resident has outbursts and antagonizes staff and peers, redirect and orient as needed. Potential for behaviors, exhibits disruptive interpersonal behavior among peers, which can escalate tensions within the facility dynamic, revised January 22, 2026. An annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident has a BIMS Score of 11, indicating moderate impairment. A March 20, 2026 psychiatric follow-up note revealed that the resident experienced intermittent agitation but remained redirectable, indicating good behavioral control and that staff reported no new behavioral issues and confirmed medication compliance. On March 31, 2026 a nursing progress note revealed that at 12:10PM Resident #26 was yelled at by Resident #16, and subsequently Resident #26 extended her left legs, contacting Resident #16's right forearm. The note indicated that the residents were separated, skin checks were performed. The note also relayed that Resident #16 utilized an extra-large bariatric chair and had difficulty independently propelling/maneuvering the wheelchair in the hallway, limiting personal space for others in the immediate area. A March 31, 2026 Behavior Observation form, revealed that physical and verbal behavioral symptoms directed towards others occurred 1 to 3 days, and that the behavior was defensive/reactive to stimuli that occurred. The form included that the resident's family and provider were notified. A skin assessment dated [DATE], revealed no new skin issues observed. A progress notes dated March 31, 2026, stated that fifteen-minute checks for twenty-four hours started for the resident. Further review of the care plan revealed no evidence of review or update of interventions regarding the March 31, 2026 incident. -Resident #16: Resident #16 (alleged victim) was initially admitted to the facility on [DATE] with diagnoses that included Borderline Personality Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, Huntington's Disease. A care plan revealed the following areas of focus: Potential risk for alteration in mood state and psychosocial well-being related to panic disorder and paroxysmal anxiety, Initiated August 15, 2023, revised on January 15, 2025. Potential for behaviors including to acting in a problematic manner characterized by verbal/physical aggression, intrusiveness toward residents, exhibits disruptive interpersonal behavior characterized by initiating or exacerbating conflicts among peers. Further review of the resident's care plan included that the resident was admitted to the secured unit, due to physical and verbal aggression, such as yelling at staff, and throwing items at staff. Initiated October 1, 2025, revised March 26, 2026. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. A nursing progress note dated March 26, 2026, revealed that the resident attended afternoon activities but was unable to participate due to continued yelling. A psychiatric follow-up progress note dated March 26, 2026, revealed that the patient was experiencing increased agitation and behavioral issues requiring active monitoring and potential medication adjustments. A nursing progress note dated March 31, 2026 at 6:41 PM, revealed that an incident occurred on March 31, 2026 at 12:10 PM in which Resident #16 was self-propelling to the front of the hallway to wait for activities, and as Resident #16 approached Resident #26, who was sitting in front of her room in the doorway, Resident #16 yelled out, get out of the way, which startled Resident #26. The note revealed that Resident #26 reacted by saying Fuck loudly and extending her left legs up, making brief contact with the right forearm of Resident #16. The floor nurse intervened at the same time as this was occurring, immediately separating the residents and assisting Resident #16 to the front of the hall. Further review of the resident's records revealed no evidence that the care plan was reviewed/revised regarding the incident that occurred on March 31, 2026. A review of the skin assessment dated [DATE], stated that a skin check was done on Resident #16's upper body which included observations of small old bruises noted on her bilateral hands and forearms, with no new discoloration, swelling or redness noted. An interview was conducted with a Certified Nursing Assistant (CNA, Staff #67) on April 3, 2026, at 8:25 AM. The CNA stated that she did not witness Resident #26 hitting Resident #16 because she was assisting another resident in a different room when she heard screaming in the hallway. When she stepped out of the room, she saw Residents #16 and #26 still yelling at each other. The CNA reported that Resident #16 was consistently anxious and sensitive and did not understand when staff asked her to be more patient. She stated that if Resident #16 wanted something, she expected staff to respond immediately, or she would continue to cry until she got her way. The CNA also relayed that she had never observed Resident #26 exhibiting aggressive behavior toward another resident, as she usually sees resident #26 being pleasant and smiling at both residents and staff. She stated that Resident #26 may have been frightened when Resident #16 yelled at her. The CNA also stated that there are often resident-to-resident altercations in the behavioral unit, and when such incidents occur, staff are trained to separate the residents immediately and monitor the situation. She also indicated that she received abuse training quarterly since she primarily works in the dementia and behavioral unit. An interview was also conducted with a Licensed Practical Nurse (LPN, Staff #42) on April 3, 2026, at 8:34 AM, who explained that abuse can take many forms, including verbal, physical, misappropriation, neglect, and sexual abuse. The LPN stated that if any type of abuse is witnessed, unwitnessed, or reported, staff are expected to notify her or any nurse present on the floor. She stated that any allegations of abuse must be reported to management immediately to ensure prompt investigation, as delays can put residents at risk. The LPN stated that in the case of resident-to-resident altercations, staff are responsible for separating the residents to safeguard their well-being. She stated that all staff receive abuse training quarterly and annually. The LPN stated that she was off duty when the incident between Residents #16 and #26 occurred. She stated that upon reading the report the following day, she was not surprised at the incident, as Resident #16 tends to fixate on things and will cry until she gets what she wants, demonstrating a lack of emotional control. A joint interview with the Director of Nursing (DON, Staff #200) and the Administrator (Staff #166) was conducted on April 2, 2026, at 11:44 AM. The Administrator stated that the facility provided consistent training on Abuse and Neglect, covering the types of abuse, the reporting process for allegations, and the actions to take if abuse is suspected. The Administrator stated that at 12:10 PM, Resident #16 was seen self-propelling down the hallway to wait for activities. When she approached the room of Resident #26, who was sitting just past the door threshold, Resident #16 yelled, Get out of the way, which startled Resident #26, who responded by exclaiming Fuck! loudly and making brief contact with Resident #16's right forearm using her left leg. The Administrator stated that the floor nurse intervened, immediately separating the two residents and assisting another resident to the front of the hallway, a skin check was performed on Resident #16, and no injuries were noted. The Administrator also stated that Resident #26, previously from the behavioral unit, was transferred to the dementia unit on Thursday, April 2, 2026. During the above interview conducted on April 2, 2026, at 11:44 AM with the Director of Nursing (DON, Staff #200) and the Administrator (Staff #166), the DON stated that staff are expected to report any incidents of abuse immediately to the DON, the nurse supervisor, and the administrator, to protect the residents. The DON further stated that Resident #26 was transferred to the dementia unit on Thursday, April 2, 2026. A policy titled 'Resident Rights: Abuse and Neglect', adopted on May 1, 2024, revealed that abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy also revealed that physical abuse includes, but is not limited to, the infliction of injury that occurs other than by accidental means, with examples that include, but are not limited to, hitting and punching.

Based on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure an allegation of misappropriation was reported to mandated entities and within the required timeframe for 1 of 24 sampled residents (#42). The deficient practice could lead to allegations of misappropriation not being investigated thoroughly and timely. -Findings include:A complaint received by the state agency on February 11, 2026, revealed that it was reported a couple of weeks prior, that Resident #42 was missing his wallet with $2,000.00, a bank card and identification. The complaint also revealed that the resident's son reported that there was a reoccurring charge on the account for about $800.00 a month. The complaint revealed that the facility helped cancel the bank card.However, review of facility records revealed that the incident was initially reported on December 16, 2025.-Regarding Resident #42Resident #42 was first admitted to the facility September 08, 2024, and re-admitted on [DATE], with diagnoses that included vascular dementia, mild, with psychotic disturbance, delirium due to known physiological condition, other gram-negative sepsis, type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with foot ulcer.An admission minimum data set (MDS) assessment dated [DATE], revealed a brief interview for mental status (BIMS) assessment score of 03, which indicated severe cognitive impairment.Review of the progress notes revealed no evidence regarding the missing funds initially reported on December 16, 2025. Review of the facility grievances dated from April 2025 to January 2026 revealed no evidence related to the resident's missing funds initially reported on December 16 2025.A late entry Social Service note dated February 10, 2026, revealed that Social Services was notified of concerns regarding a missing wallet and bank card. The note included that in accordance with mandatory reporting requirements, Adult Protective Services (APS) intake was completed. However, there was no evidence that the state agency was notified regarding misappropriation.The facility provided a type written report dated February 10, 2026, titled Social Services Incident Timeline. The report revealed that on December 16, 2025, Resident #42's son met with Social Services (SS/staff #109) and reported concerns regarding financial charges appearing on the resident's account of which he was unaware. The report indicated that Social Services contacted the Business Office for clarification regarding potential facility-related charges. The report relayed that the Resident's son intended to cancel the debit/credit card associated with the questioned transactions. The report relayed that an interdisciplinary discussion was conducted, during a clinical team meeting due to the reported unexplained charges and lack of supporting documentation despite multiple requests. The report indicated that the potential financial exploitation would be reported to APS. However, there was no evidence in the resident's clinical record that the state agency, or that the Administrator were notified regarding the incident on December 16, 2025.A joint interview was conducted on April 2, 2026, at 11:44 AM with the Director of Nursing (DON/Staff #200) and the Administrator (Staff #166). The Administrator stated that the facility provided consistent training on Abuse and Neglect, covering the types of abuse, that included misappropriation, the reporting process for allegations, and the actions to take if abuse is suspected. The Administrator (Staff #166) stated that for misappropriation, the social services department typically takes the report and staff will start the search in the resident's room, expanding outward if necessary. She also stated that the Department of Health Services, Ombudsman, and Adult Protective Services should be notified to start the investigation process, summarize the data, and submit the five-day report. The Administrator further stated that she would start the initial report and the investigation, notify the family and physician just like with abuse or neglect. The Administrator relayed that she has a tracker for all types of abuse, including misappropriation, which is reviewed at Quality Assurance (AQ) meeting every month to see if there are trends/multiple grievances. The Administrator stated that Resident #42's son reported a misappropriation of funds in December 2025, and she was not aware of the incident. She added that the resident doesn't have a history of missing items, as far as she remembers, and had only been at the facility for a year. She added that she's not really sure what happened because they learned about the missing items when the son spoke to the social worker, and the social worker asked whether there were any charges on the card, since Resident #42's son stated that the card had been canceled and that the card was in the resident's possession the whole time. She added that when the facility asked for a card statement, the family failed to provide it. Both the Administrator and DON (Staff #200) stated that failing to report an incident delays the response and investigation process.During the joint interview conducted on April 2, 2026 at 11:44 AM the DON (Staff #200) stated that staff are expected to report any incidents of abuse immediately to the DON, the nurse supervisor, and the administrator, to protect the residents.A policy titled, Resident Rights: Abuse and Neglect, adopted on May 1, 2024, revealed that it is the facility policy to provide professional care and services in an environment that is free from misappropriation of property. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigation of allegations, that include the seven federal components of prevention and investigation. Financial abuse includes misappropriation, exploitation or otherwise taking advantage of a resident's money or property temporarily or permanently. If abuse is suspected the facility will notify the appropriate/designated organization/authority (state agencies) that in investigation is being initiated immediately following intervention for the resident's safety. Take actions related to resolving resident and family issues/concerns/allegations and record. Report the investigation findings to the appropriate state agencies, notify law enforcement authorities if indicated. All allegations and/or suspicions of abuse will be reported to the Administrator immediately, and will be reported to the appropriate state agencies immediately after the initial allegation is received, a final investigation report will be submitted to the appropriate state agency within 5 working days.

Based on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure 1 of 24 sampled residents (#118) was protected from a preventable accident, related to a fall from the bed during brief change. The deficient practice could lead to physical injury of a resident.-Findings include:Resident #118 was initially admitted to the facility on [DATE], with diagnoses that included quadriplegia, major depressive disorder, anxiety disorder, insomnia, neuromuscular dysfunction of bladder, and other problems related to life management difficulty.A care plan revised November 3, 2023, revealed Resident #118 had limited physical mobility.An annual minimum data set (MDS) assessment dated [DATE], revealed Resident #118 had a brief interview for mental status (BIMS) assessment score of 15, indicating intact cognition. Section GG revealed the resident had limited range of motion on both sides of his upper and lower extremities. Additionally, the resident was dependent on staff for rolling left and right in bed. Section J revealed the resident had no falls since admission / entry.A Fall Scale Evaluation dated September 28, 2025, revealed Resident #118 was a high fall risk.A care plan focus for limited physical mobility revealed a new intervention dated October 23, 2025, and included for 2 staff to assist with bed mobility.A nursing note dated November 5, 2025, revealed that it was brought to the nurse's (Staff #34) attention that Resident #118 had a fall incident at approximately 11:10 a.m., and that the nurse assessed the resident immediately. The documentation included that the resident was on the floor and was assisted back to bed. The note revealed per the staff who was changing the brief, the resident was positioned on his right side with the head and body on the edge of the bed. The note included the resident slipped from this position, and fell to the floor hitting his head, with his face and body facing downward. The note included the resident was complaining of knee pain, and was alert and oriented x 4, and able to follow commands. The documentation revealed there was no head or body injury related to the fall incident noted, small scratches on the right side of the buttock, and that the resident complained of knee pain. The note included that the provider was notified and gave orders to send the resident to the hospital, and that the resident refused to go to the hospital.A physician/practitioner note dated November 5, 2025, revealed that the nurse reported the resident hit knees and head with staff present, and that the resident's right knee was worse than left, with a small abrasion less than 0.5 centimeters on the right knee.A care plan dated November 6, 2025, included that the resident had an actual fall on November 5, 2025, and that interventions included to reposition grab bars, re-educate on repositioning done with nursing staff, floor mat to right side of bed, and staff education provided for proper turning and positioning while in bed.A therapy note dated November 12, 2025, revealed that a physical therapy screen was completed, and that the resident would benefit from bilateral repositioning rail to decrease fall risk when repositioning in bed for pressure relief and/or brief changes.A late entry interdisciplinary team (IDT) note dated November 12, 2025, revealed the resident accidentally slipped during activity of daily living (ADL), and that the root cause was that the resident was repositioned to his right side during ADL and slipped, causing him to fall. Interventions included to change low air loss mattress to concave mattress for safety, 2 staff needed during turning and repositioning, turn resident to weak side of his body during ADL, and to instruct resident to use his strong side of his body to hold onto the grab bar.A nurse's note dated November 18, 2025, revealed the nurse talked with the resident and his family about the use of long side rails, and that they are considered restraints, and that a consent must be signed. Additionally, with the long siderails, broken limbs could occur if resident fell out of bed due to the fact he is on an air mattress that has a plastic cover and sheets, and he can slide off the bed. Resident #118 and his family decided to use bolster pads on both sides of the bed that are secured to the bed. The note included the nursing staff would be able to do personal care and the bolsters would not need to be removed, and he would not slide out of bed when being repositioned. The note revealed that Resident #118 required care for all ADLs, and that the bolsters would be ordered and applied as soon as they arrived.An interview was conducted on March 31, 2026, at 11:15 a.m. with Resident #118, who stated that there was an incident a few months ago where staff were changing him and he fell off the edge of the bed and hurt his knee and his head.An interview was conducted on April 1, 2026, at 1:41 p.m. with a certified nursing assistant (CNA / Staff #48), who stated that some residents require 2 staff to assist with rolling the resident on the side in bed for changing. Staff #48 stated that if the resident was at a dependent-level for care, then likely 2 staff would be needed, unless the staff was a large person and the resident was small. Additionally, Staff #48 stated that if the resident were paralyzed, then 2 staff would be needed to safely roll the resident in bed. Regarding Resident #118, Staff #48 stated that she was familiar with caring for the resident, and that he was paralyzed and needed two staff to roll the resident in bed. Regarding the fall incident, Staff #48 stated that she was present for the incident. Staff #48 stated that Resident #118 was unable to move himself at all, and that she and another CNA (Staff #14) were changing the resident, with one CNA positioned on each side of the bed, and were attempting to roll the resident onto his side facing Staff #48. Staff #48 stated that the other CNA (Staff #14) may have moved too quickly, and that the resident was positioned too close to the edge of the bed nearest to Staff #48. Staff #48 stated that maybe we overturned him a little, and the resident suddenly fell off the side of the bed onto the floor. Regarding the cause of the fall, Staff #48 stated that there was not enough room for the resident to be rolled onto his side, and that the CNAs should have moved him over in the bed to the opposite side first, before attempting to roll him, and that it should have been done more slowly. Staff #48 stated that it was an accident, and that she felt awful that it happened.An interview was conducted with a CNA (Staff #14) on April 2, 2026, at 7:18 a.m., who stated that she and the other CNA (Staff #48) were changing Resident #118, and that the resident was too close to the edge of the bed before they started to roll him. Staff #14 stated that when she went to roll him over, and the other CNA (Staff #48) was pulling the resident toward her as well, the resident then slipped off the edge of the bed quickly and fell to the floor onto his stomach. Staff #14 stated that the resident was yelling, the nurse came in to assess the resident, and afterward, the resident refused to go to the hospital for evaluation. Staff #14 stated that if the CNAs had pulled the resident more toward the opposite side of the bed prior to rolling him, then that could have prevented the accidental fall from the bed. Staff #14 stated that they received training after the incident to position the resident adequately before providing assistance with rolling, and training on fall prevention.A telephonic interview was conducted with a licensed practical nurse (LPN / Staff #34) on April 2, 2026, at 10:15 a.m., who stated that she was the floor nurse on the day of Resident #118's fall incident. Staff #34 stated that the CNAs were turning the resident in bed and that the resident accidentally slipped off the edge of the bed and fell to the floor. Staff #34 stated that she did not recall the resident complaining of pain after the incident. After the incident, Staff #34 stated that there were interventions placed so that there were always two CNAs when changing and rolling the resident, and one CNA would always have their hands on the resident holding him to ensure he does not fall.An interview was conducted on April 2, 2026, at 10:35 a.m. with a unit manager and LPN (Staff #86) who stated that for a paralyzed resident or one who is dependent for care, that the procedure for rolling or turning that resident in the bed included to use a draw sheet to move the resident so that there is no pulling or jerking on the resident which could cause injury. Additionally, Staff #86 stated that if there were two staff, that it would be necessary for them to communicate to coordinate their movements at the same time, such as counting 1,2,3 before moving the resident, that way all parties would be ready. When rolling a resident to the side, Staff #86 stated that a resident would be pre-positioned to the opposite side of the bed so that the resident could have room to be rolled without rolling off the side of the bed. Regarding Resident #118, Staff #86 stated that she had heard about the fall incident, that the resident was being changed and accidentally slid off the edge of the bed during care with the staff. Staff #86 stated that she did not know any further details, and that she believed the resident did not sustain any injuries.An interview was conducted with the Director of Nursing (DON / Staff #200) on April 3, 2026, at 8:45 a.m., who stated that the facility staff prevent accidents by following protocol and policies. The DON stated that the procedural steps of safely turning / rolling a dependent resident in the bed included to take into consideration the resident's care plan interventions, to have one staff positioned on each side of the bed, to lift and move the resident more toward the opposite side of the bed (than the side rolling toward) in order to provide adequate space for rolling, and then to assist the resident with rolling. The DON stated that if those steps were not completed, then the resident could fall from the edge of the bed and get injured. The DON stated that she was not familiar with Resident #118's fall incident because it happened before she was employed at the facility. The clinical record was reviewed, and the DON stated that it appeared from the documentation as if the CNA had the resident positioned on his right side and on the edge of the bed, and that the resident slipped from that position and fell to the floor. The DON stated that it would not meet her expectation as far as following safe procedure to prevent a fall.An interview was conducted with the Administrator (Staff #166) on April 3, 2026, at 9:01 a.m. who stated that regarding Resident #118's fall incident, that she believed there were two CNAs assisting the resident at the time. She further stated that after the incident, several interventions were put into place including ordering of mobility bars for the resident's bed, immediate education provided to the two CNAs, and ordering bolsters for the resident's bed which he later declined. The Administrator stated that improved bed mobility assistance from the CNAs, in addition to the mobility bar, would have helped to prevent the accident.Review of the facility policy titled Moving Resident in Bed, dated May 1, 2024, revealed that if turning the resident toward you: reach over resident and firmly grasp the resident's shoulder and hip that are farthest from you, and shift your weight from the forward leg to the backward leg as you roll the resident toward you. If turning resident away from you: move resident to side nearest you, place arms under each area of body and move slowly and gently, flex arm nearest you across the resident's chest and flex nearest knee, slide one arm under resident's shoulder and back and other arm under hips, and pull your arms toward you while rolling resident onto side.Review of the facility policy titled Fall Risk Assessment, dated May 1, 2024, revealed it is the policy of this facility to identify the resident who is at risk for potential falls, and to initiate a preventative plan of care to reduce fall occurrence. The purpose of the policy was to ensure that the facility identifies each resident at risk for accidents and/or falls, and adequately plans care and implements procedures to prevent accidents.

Based on review of the clinical record, interviews, and review of the facility's policies and procedures, the facility failed to protect the rights of one resident (#6) to be free from abuse from another resident (#9). The deficient practice could lead to sustaining injuries.Findings include:Related to Resident #6-Resident #6 was admitted to the facility on [DATE] with diagnoses that includes fusion of the spine, lower back pain, and Major Depressive Disorder.Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #6 completed a Brief Interview for Mental Status (BIMS) and scored a 15 which indicated he was cognitively intact.Review of the Progress Notes in the clinical record, revealed a Nurses Note created by Registered Nurse (RN/Staff #65), dated February 2, 2026 at 7:01 P.M. The note indicated that around 6:35 P.M., Resident #6 reported that he was physically attacked by his roommate. The same note further revealed that there were visible injuries which included a skin tear on his left forearm and redness on the right side of his neck.A second Nurses Note, dated February 2, 2026 at 11:41 P.M., indicated that Resident #6 reported that his roommate (Resident #9) had the volume on his television too loud and they had a verbal disagreement and the roommate (Resident #9) then grabbed Resident #6 around the neck and shoulder area. The note also revealed that Resident #6 denied hitting Resident #9, however, Resident #9 was observed to have a minimal area raised on the left cheekbone below the eye with no discoloration or pain. The note further detailed that both residents were separated and skin checks were completed. The other resident (Resident #9) was then moved to another hall.A skin assessment, dated February 2, 2026 at 11:14 P.M. indicated that Resident #6 had a left forearm skin tear due to physical contact/aggression with (another) resident. It was also noted that wound care was done by the nurse on duty (Staff #65).Related to Resident #9-Resident #9 was admitted to the facility on [DATE] with diagnoses that includes cellulitis of the Right and Left lower limb, Cerebral Palsy, and Scoliosis.Review of the admission MDS, dated [DATE], revealed Resident #9 completed a BIMS and scored a 15 which indicated he was cognitively intact.A review of the Progress Notes in the clinical record, revealed a Nurses Note, dated February 2, 2026 at 8:10 P.M., indicated that Staff contacted a crisis center and they sent someone to the facility to evaluate Resident #9.Another Nurses Note, dated February 2, 2026 at 9:15 P.M. Resident #9 was transferred to the crisis center by crisis staff and that he was alert and oriented X4. A Nurses Note, dated February 2, 2026 at 11:12 P.M. indicated that Resident #9 reported that his roommate (Resident #6) did not believe that he had the television volume lowered which resulted in the two Residents having a verbal disagreement. The note further indicated that Resident #9 alleged that Resident #6 hit him on the left side of the face and Resident #9 then reacted to the hit by grabbing Resident #6 by the neck and shoulder area. The same note also indicated that Resident #9 had minimal area raised on left cheekbone below the eye with no discoloration or pain. Both residents were separated and had skin checks completed. Resident #9 was reassigned to another hall and received orders for a crisis center evaluation.The Care Plan identified a focus on Resident #9's behavioral disturbances which were identified as physically aggressive, impulsive, verbal aggression related to poor impulse control, and a mood disorder. Interventions included 15-minute checks, reduce noise, dim the lights, and giving the resident as many choices as possible.An interview was conducted with Resident #6 on February 10, 2026 at 1:10 P.M. Resident #6 shared that his former roommate had started strangling him after he had asked him to turn down the volume on the television. Surveyor observed a quarter sized scab on Resident #6's left arm. Resident #6 indicated the scab was from a cut he sustained when he was being attacked by Resident #9 and that he also had redness on his neck. Resident #6 shared that he had gone outside to report the incident to the nurse in the hall. He also shared that he was not happy when Resident #9 called him a liar when he told the nurse that he did not hit Resident #9.An interview was conducted with Certified Nursing Assistant (CNA/Staff #6) on February 11, 2026 at 12:33 P.M. Staff #6 confirmed that she was working the unit when the altercation between Resident #6 and #9 took place. However, she shared that she did not witness the incident, only had a conversation with Resident #6 after it happened. She shared that she heard Resident #6 tell a nurse that his roommate had choked him. Staff #6 indicated that she then spoke with Resident #6 and he had told her that his roommate had choked him because he had asked him roommate to turn down the volume on the television. She further indicated that she did not see any marks on Resident #6's neck but did see some scratches on the left arm.A telephonic interview was attempted with Staff #65 twice during the survey. However, a phone call was not returned to Surveyor by the conclusion of the survey.An interview was conducted on February 11, 2026 with the Director of Nursing (DON/Staff #22) at 12:47 P.M. When asked to explain the resident to resident altercation between Resident #6 and #9, Staff #22 indicated that, according to the report, the residents were in their room and were having issues with the television being loud. They had gotten into an argument and she was not sure who grabbed who on the neck. Staff #22 then check the clinical chart and shared that Resident #9 had gotten close to Resident #6 and grabbed Resident #6 around the neck. She indicated that she believes there was redness in the neck area. She also shared that both residents were separated and Resident #9 was moved to another hall to prevent another incident. When asked if this situation would be considered abuse, she initially indicated that for her, it was not abuse but it was a behavior because residents were mad. She further explained that the residents were emotional; the altercation was a spur of the moment thing when you're trying to stop the person from coming closer to you. Staff #22 indicated that abuse was a big word and is an intentional act- she was not there so she did not know if the situation was intentional. Staff #22 acknowledged that both residents were alert and oriented. She then acknowledged that the situation could probably be abuse.An interview was conducted on February 11, 2026 at 2:56 P.M. with the Administrator/Staff #29. Staff #29 explained that Resident #6 had told Resident #9 to turn down the television and then they had an argument. Resident #9 reported that Resident #6 punched him and then Resident #9 went after Resident #6's neck with both hands. She shared that Resident #6 had red marks on his neck and a skin tear on his arm. She further shared that Resident #9 had a red mark on his left cheek. Staff #29 also added that it was a very aggressive altercation because Resident #9 went under the curtain, in the room, and he was very angry and admitted that he was angry. Staff #29 further added that Resident #6 has been at the facility for a long time and he has never had an altercation with other residents before. Staff #29 shared that she would categorize this incident as abuse as it was an abusive situation towards Resident #6.Review of the facility's 5-day report indicated that based on the facility's investigation of the incident, they had verified the allegation of resident to resident abuse. The 5-day report included a signed statement from Staff #65. The statement indicated that Staff #65 was exiting another resident's room around 6:35 P.M. when she was approached by Resident #6. The statement further indicated that Resident #6 reported that he was physically attacked by his roommate (Resident #9). Resident #6 explained that he was strangled around the neck and grabbed on the arm which resulted in a skin tear to the left forearm. The statement also shared that Resident #6 was moved closer to the medication cart for his safety and that he had called 911 himself. His injuries were treated and a skin assessment was completed. It further shared that redness was observed on the right side of his neck. The statement continued to indicate that Staff #65 then went into the room to check on Resident #9 and he stated that he was punched on the left side of the face by Resident #6. The statement also indicated that the incident occurred following a disagreement about the television volume.Review of the facility's policy, titled, Abuse and Neglect, indicated that it was adopted on May 1, 2024. The policy indicated that the facility will provide an environment that is free from any type of abuse. It defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. It also identified the 7 types of abuse with physical abuse being one of them.

The facility failed to ensure a signed consent was obtained before starting a new psychotropic medication for one resident, #4. The deficient practice could lead to a resident's responsible party not being informed of the risk and benefits of a resident's medications. Findings include:Resident #4 was admitted to the facility on [DATE] with diagnoses that included Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; Urinary Tract Infections (UTI); and repeated falls.Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #4 underwent a Brief Interview for Mental Status (BIMS) and scored a 02 which indicated the resident was cognitively impaired. The same MDS further revealed that Resident #4 exhibited behaviors such as physical, verbal, and other behavioral symptoms that are not directed towards others, however it did significantly interfere with her care and participation in activities. It also noted that Resident #4 also exhibited rejection of care and wandering.Review of the resident's orders revealed that Resident #4 had an order put in on February 3, 2026 for Hydroxyzine. The order indicated Resident #4 was to be administered 1 tablet by mouth, 50 milligrams (mg), every 6 hours as needed for Anxiety as evidenced by calling out.Resident #4's Medication Administration Record for February 2026 indicated that she received four doses of hydroxyzine between February 3, 2026 and February 7, 2026.Review of the Progress Notes in the clinical record revealed a Psych Evaluation note, dated February 3, 2026 at 10:45 A.M. The note indicated that Resident #4 was to start Hydroxyzine 50 mg by mouth every 6 hours as needed for anxiety.Review of a second progress note, dated February 7, 2026 at 12:20 P.M., revealed that the provider was contacted related to an increase in Resident #4's behaviors. A new order was received to increase Hydroxyzine from 50 mg to 75mg every 6 hours as needed.A third progress note, dated February 7, 2026 at 6:24 P.M. revealed that after the provider had a conversation with Resident #4's family member, her Hydroxyzine was put on hold by the provider pending a re-evaluation.Further review of the clinical record did not reveal a signed consent by the responsible party for the Hydroxyzine 50 mg.An interview was conducted on February 11, 2026 at 10:43 A.M. with Licensed Practical Nurse (LPN/Staff #10). Staff #10 explained that consents for psychotropic medications are received by the nurse working the floor when the resident is admitted . She further explained that the consent needs to be signed by the resident or responsible party prior to administering the medication. She added that if the family is not able to come in to sign the form, they can provide verbal consent as well. Staff #10 confirmed that she was familiar with Resident #4 and that she was receiving Hydroxyzine. After looking in the clinical record, Staff #10 shared that she was unable to locate a signed consent for the Hydroxyzine. Staff #10 explained that the medication should not have been administered without consent however, she added that the family member knew the Hydroxyzine was being administered. Staff #10 added that she had asked the family member to sign the consent form because she had agreed to Resident #4 taking the medication during the care plan meeting but the family member had decided, at the last minute, to not sign the form. When asked if Staff #10 attended the care plan meeting, she acknowledged that she did not but the family member had told her that it was discussed at the meeting.An interview was conducted on February 11, 2026 at 11:46 A.M. with the Behavioral Health Unit Manager (LPN/Staff #37). Staff #37 explained that her nurses will do the admissions paperwork and this also includes obtaining consents for psychotropic medications. She indicated that she was familiar with Resident #4 and added that there should be signed consents for her psychotropic medications in the chart. However, she was not able to locate the signed consent for Hydroxyzine. Staff #37 stated that she would check with medical records to see if the form had been uploaded. After a few minutes, Staff #37 shared that medical records confirmed that they did not have the form as well. Staff #37 explained that nurses are not to administer Hydroxyzine without a signed consent so she would need to look at the Medication Administration Record (MAR) to see if it was administered. After reviewing the MAR, Staff #37 shared that the Hydroxyzine was administered on February 4, 5, 6, and 7. She added that it looks like the Hydroxyzine was administered without the signed consent which was not protocol and it did not meet her expectations.An interview was conducted on February 11, 2026 at 1:37 P.M. with LPN/Staff #86. Staff #86 explained that Resident #4 came into the facility with Mirtazapine and when she had spoken with the family member, the family member reported that Resident #4 was on Seroquel when she was in the hospital and the family member did not want Resident #4 on Seroquel while she was at the facility. Staff #86 recalled telling the family member that Resident #4 was hitting staff and they were getting injured. This has led the psychiatrist wanting to do labs to rule out any underlying causes of the increase in behaviors. Staff #86 further recalled that the family member was okay with the lab work being done but she wanted to ensure that non-pharmacological interventions were being tried first. Staff #86 acknowledged that the facility would need a signed consent before administering Hydroxyzine, which Staff #86 explained was for Anxiety. She was not able to locate a signed consent and stated that it might not have gotten signed. Staff #86 also confirmed that Resident #4 was administered Hydroxyzine four times. She added that nursing staff were not following protocol for administering psychotropics. She also added that Staff #37 was putting together an education on consents and that she was overseeing all provider orders to prevent this situation from happening again.An interview was conducted on February 11, 2026 at 2:04 P.M. with the Director of Nursing (DON/Staff #22). Staff #22 explained that the nurse getting an order, containing psychotropic medications, and putting it into the system is responsible for getting the consent. If a Nurse Practitioner puts the order in, a nurse still needs to verify the order and obtain the consent. She added that prior to administering psychotropic medications, nurses need to go into the system to look for the signed consent. Then they would be able to administer the medication. Staff #22 was not able to locate a signed consent form for Hydroxyzine and identified that the medication was administered to Resident #4, four times. She added that staff should not have administered the medication before the consent was signed. She added that it looked like the nurses did not check the system for the signed consent and assumed that it was done. Staff #22 shared that it was important to have signed consent for residents who are taking psychotropic medications so the family/resident are aware of the medications the resident is taking as well of the side effects of those medications.Review of the facility's policy and procedure, titled Psychoactive Drug Use, dated May 1, 2024, indicated the purpose of the policy was to ensure communication of risks and benefits concerning the need of chemical restraints to residents and responsible parties. The policy and procedure's section 8 stated that all residents and/or responsible parties will be asked to make an informed choice concerning the use of a psychoactive drug. In order for an informed choice to be made, potential negative outcomes (risks) and benefits of the drug use will be explained.

The facility failed to ensure an allegation of abuse for one resident (#4) was reported to the State Agency (SA) within the timeframe established by regulations. The deficient practice could lead to continued abuse of residents.Findings include:Resident #4 was admitted to the facility on [DATE] with diagnoses that included Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; Urinary Tract Infections (UTI); and repeated falls.Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #4 underwent a Brief Interview for Mental Status (BIMS) and scored a 02 which indicated the resident was cognitively impaired. The same MDS further revealed that Resident #4 exhibited behaviors such as physical, verbal, and other behavioral symptoms that are not directed towards others, however it did significantly interfere with her care and participation in activities.Review of the care plan indicated that Resident #4 had the potential for behaviors which required staff to allow the resident time to respond to directions or requests due to her dementia.A facility self-report complaint was received by the SA on February 9, 2026 at 4:31 P.M. The self-report indicated that the alleged abuse had taken place on the evening of February 8, 2026 and was not reported sooner, to the administrator, because the staff member had stated that she was in shock. The staff member reported the alleged abuse to the administrator on February 9, 2026.A telephonic interview was conducted with Licensed Practical Nurse (LPN/Staff #34) on February 11, 2026 at 9:13 A.M. She explained that she often gets training on abuse and knows that she is to report it to the Administrator. She said, except when you have a lot going on, the reporting might be delayed but she knows that she is to report it soon. She indicated that she did not report the alleged abuse to the administrator when it happened on February 8, 2026 because she was in shock when she saw it and there was a lot going on. Staff #34 recalled that the alleged abuse took place on Sunday night which was February 8, 2025 between 11:30 P.M. and midnight. She was working the 6:00 P.M. to 6:30 A.M. shift. She had gone home without reporting it because she was in shock and after thinking about the situation, she decided to go to the facility and report it the next day. Staff #34 explained that when the situation happened, she was unaware that allegations of alleged abuse needed to be reported to the administrator right away and that she was sorry for not reporting it sooner. Staff #34 explained that the risk of not making a report sooner, was that the residents could continue to get hurt.An interview was conducted on February 11, 2026 at 10:43 A.M. with LPN/Staff #10. She shared that they get training on abuse weekly or every two weeks. Once the training is done, they have to complete a test. Staff #10 explained that allegations of abuse is to be reported to her supervisor and the Administrator immediately. If it was not reported immediately, there would be a risk of harm to the resident. She added that they could be penalized or fired for not reporting right away because it was their job to report suspected abuse.An interview was conducted with the Administrator/Staff #29 was conducted on February 11, 2026 at 1:22 P.M. Staff #29 explained that Staff #34 was reported the suspected abuse to her around 2:00 P.M. on February 9, 2026. She further explained that the staff member had gone home after her shift and then came back to the facility and reported the suspected abuse. Staff #29 shared that Staff #34 thought she had 24 hours to report the suspected abuse and that Staff #29 told her that she had 2 hours to report, not 24 hours.An interview was conducted with the Director of Nursing (DON/Staff #22) on February 11, 2026 at 2:04 P.M. She explained that suspected abuse is to be reported to the administrator, who is the abuse coordinator, within 2 hours. She further explained that the risk to the residents, for not reporting abuse in a timely manner, could be emotional distress, they could become depressed, and the resident's safety would be compromised. Staff #22 added that you have to protect the person that is being abused, not the abuser. It has to be handled right away. When asked if the delay in reporting suspected abuse of Resident #4 met her expectations, she indicated that it did not.Review of the facility's policy and procedure titled Abuse and Neglect, indicated that it was adopted on May 1, 2024. The procedure indicates that if abuse/neglect is suspected, the facility will notify the appropriate/designated organization/authority (State Agencies) that an investigation is being initiated immediately following intervention for the resident's safety. It also indicates that all allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect one resident (#511) rights in a manner that promotes enhancement of the resident's quality of life by having her own cell phone to access persons and services outside the facility. The deficient practice could lead to residents' rights being violated.Findings include:Resident #511 was readmitted to the facility on [DATE] and originally admitted on [DATE], with diagnoses that included type 2 diabetes mellitus, factitious disorder imposed on self, borderline personality disorder, major depressive disorder, anxiety disorder, and Huntington's disease.Resident's Clinical Resident Profile revealed that she was her own responsible party/representative.The resident had another care plan initially dated on August 15, 2023, and revised on January 15, 2025, which revealed the resident has a potential risk for alteration in mood state and psychosocial well-being related to panic disorder. The goal is for the resident or family will to understand the disease process and to be able to express feelings of anxiety and fear. The interventions included to encouraging alternative communication with visitors and/or family members, such as phone calls, Face-time, Skype, video phone, if possible and encourage the resident to participate in supportive visits and /or in room activities that are important and vital to the resident; and staff are to anticipate and meet resident needs. Check in with the resident as needed to reflect upon underlying emotional distress, difficulty with self-regulation, or unmet social or psychological needs. Addressing this behavior involves exploring its root causes, fostering constructive communication skills, and promoting positive engagement within the peer environment; consider the resident's and family preference for care such as: showering/bathing time, meal time and choice, activities, religious practices, bed/awake time.Another focus care plan review, initially dated on August 2, 2023, and revised on January 15, 2025, revealed that the resident was admitted to the behavioral secure unit related to Huntington's diagnosis. The intervention included for staff members to encourage resident's independence, and to assess for a lower level of care as needed.The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS score of 15.0, indicating that the resident was cognitively intact. The assessment also revealed that physical and verbal behavioral symptoms occurred. In addition, the assessment revealed that resident exhibited rejection of care and wandering behaviors.A review of facility documentation dated October 30, 2025, revealed Resident #511 was denied an appointment of a public fiduciary to oversee her legal and financial decisions, ensuring care planning, medication management, and protection from self-harm due to her BIMS score of 15 out of 15 on July 31, 2025. Further, per the document, Resident #511 has a third party as her payee, and a sister as her Surrogate Decision Maker, following the resident's wishes if they are known.A progress note, Orders-Administrative Note, dated January 22, 2026, revealed a behavioral health charting. Per the document, the resident started complaining about her phone, asking the staff to use their online account to buy her a new phone. The resident was informed that the business office and the social service will be notified to look into her request.Review of resident's financial statement revealed that the Resident had a balance in her personal fund managed by the facility in the amount of $543.00 as of January 22, 2026.An activity observation was conducted on January 26, 2026, at 1:59 PM, held in the first-floor dining room. Resident #511 was observed sitting in her wheelchair on one end of the table, slightly away from the tables where the other residents were seated. Resident #511 was interacting with a staff member who was holding a cellphone showing Resident #511 pictures of products online.An interview was conducted on January 27, 2026, at 1:58 PM with business office manager (BOM/Staff #44). Staff #44 stated that, regarding spending requests from residents with behavioral concerns, she will use the residents' trust fund to purchase items for their spend down. She also said that if a resident has cognition impairment, their finances will be handled by a third party. If the resident needs a spend down, she cannot let their account balance go over $2000.00. Therefore, she will ask the resident or the certified nursing assistants (CNAs) what the residents would need, such as socks, shoes or even a foam mattress. She said that the spend down receipts are filed monthly and audited. Regarding Resident #511, she said that the resident can verbalize her needs and had a list asking for clothes, coloring books, and if Resident #511 had enough money in her trust fund, Staff #44 would use the resident's trust fund to purchase the resident's request. Staff #44 stated that Resident #511 requested a cellphone but was waiting for the resident's sister to make the decision because the resident had overindulged in food spending $1000.00 using her debit card to order food via her cellphone. Staff #44 said that the resident does not have a cellphone now, and that is why Staff #44 was waiting for the Resident's sister to make the decision. Staff #44 said the reason why the resident does not have a cellphone was that the Resident broke her android cellphone during her behavior episode, resident threw it and it cracked. Staff #44 said that the resident's sister was aware. Regarding Resident #511 finances, Staff # 44 said that the resident receives money from a third party that manages her finances, and the money Resident #511 receives goes on her debit card. Staff #44 stated that she only handles the resident's trust fund, which she needs to keep below $2000.00 at all times. She said that Resident #511 does not have a shared cost, so everything the resident needs comes out of the Resident's trust fund account, and the third party that manages the resident finances sends $100.00 per month in a check, then the check gets transferred to the Resident's debit card. Resident #511 can also get money through the front desk for up to $50.00 per day from Monday through Friday and $25.00 per day on the weekends per CMS guidelines. Further, Staff #44 stated that the last time she communicated with the resident's sister was on November 13, 2024, at the request of the Social Service Director regarding the status of the resident's power of attorney (POA). Lastly, Staff #44 stated that their social services department handles communication with the resident's sister.An interview was conducted on January 27, 2026, at 3:58 PM with Resident #511. Resident #511 stated that last year her cellphone broke all of a sudden, that it busted in half, and she does not know how to get another cellphone. She said that her sister is the main person the staff talks to. She also said that she does not know the contact number of her sister; and she thinks that the facility made her sister her power of attorney. Further, she said that she has not spoken to her sister since last year, and she does not communicate with her sister because she does not have a cellphone anymore. During the interview, the resident kept on saying that she needed a cellphone.An interview was conducted on January 27, 2026, at 4:13 PM with licensed practical nurse (LPN/Staff #119). Staff #119 stated that she is not the regular nurse at the behavioral unit, and the nurse assigned to the unit was on vacation. Regarding Resident #511, Staff #119 said that she does not know if the resident has a cellphone.An interview was conducted on January 27, 2026, at 4:18 PM with certified nursing assistant (CNA/Staff #165). Staff #165 stated that when Resident #511's call lights is on, the resident immediately wants to get up, and the resident becomes angry and accuses everyone. Staff #165 stated that the resident told him that he had stolen her table and credit cards. Staff #165 said that Resident #511 used to have a cellphone, but her cellphone broke last month.An interview was conducted on January 27, 2026, at 5:01 PM with social service director (SSD/Staff #60,) and present during the interview in the social service office was the case manager (Staff #6). The SSD stated that the power of attorney (POA) process included an application form for POA medical and durable to be completed, and the SSD stated that she has been told that per Arizona State Statues, the the Public Fiduciary comes into play if all other options are exhausted. Regarding Resident #511, the SSD stated that the resident's public fiduciary was denied on October 30, 2025. The SSD stated that the public fiduciary petition process, with the help of the psych nurse practitioner, for Resident #511 was started because of the resident's refusals for medications and refusals for needed the extraction of her black dentition, which became a safety concern. The SSD also said that the resident's sister refused to take part as the resident's POA. The SSD said that the resident's sister was not cooperative. Further, the SSD stated that around September/October of last year, Resident #511 had access to her funds, and Resident #511 placed herself in danger by significantly gaining weight by ordering pizza daily and the resident had spent $1000.00. Further, the SSD stated that Resident #511 made an accusation about her phone, for instance, that her phone charger was broken; and there was a concern about the phone charger would get hot and potentially hurt the resident. The SSD stated that the interventions implemented were to keep the phone charger at the nurses' station; the resident to make phone calls at the nurses' station; the resident has access to call her sister via phone located in the unit; and access to social service department. The SSD stated that everybody is allowed a cellphone, but Resident #511 cellphone was a safety concern due to her phone charger getting hot; significant weight gain from ordering food through a cell phone; and resident was petitioned for public fiduciary regarding safety concern. The SSD stated that the Resident's cellphone was part of the discussion with her assistant social service (Staff #169) and will be up for discussion at the behavioral health meeting this week, on Thursday. The SSD said that Resident #511 has the right to access a phone. The resident's own cellphone was deemed unsafe; the resident's access to a phone was through the use of the facility phone, and the SSD reported that Resident #511 has not had a cellphone for several months. The SSD stated that the Resident's BIMS score was 15.0, and her petition for the Public Fiduciary was denied, with the resident described as non-compliant.An interview was conducted on January 28, 2026, at 4:17 PM with the Director of Nursing (DON/Staff #25). The DON stated that her responsibilities included clinical management; she is responsible for license nurses, CNAs, and other disciplines such as housekeeping, dietary and consultants. Regarding resident cellphones, she stated that because of the generation now, having a cellphone for the elderly was the only way for them to call their family; communicate outside; maybe their cellphone is their security to get some health services; and use their cellphone to buy something from online shopping or order food they like. The DON stated that having a cellphone facilitates communication both outside and with their family. She said that she heard about a resident with a broken cellphone that needs to be repaired. The DON said that the phone was not repairable, she needed to assist the resident in communicating with their family, to do so, she would refer the issue to social service. She said that the CNA should inform the charge nurse, and the charge nurse should notify the social service. Her expectation regarding the resident's cellphone with a BIMS score of 15.0 was to ask staff to help buy the phone with the resident's own money; the resident has the right to have their own phone; social services and the business office should assist the resident to buy the phone.Review of facility policy titled Resident Rights, adapted on May 1, 2024, revealed that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The Resident has the right (1) to be treated with consideration, respect, and full recognition of his or her dignity and individuality, (16) to keep and use personal clothing and possessions in the Nursing Facility as space permits unless doing so would infringe upon the rights or safety of other residents, and (18) to reasonable access to a telephone for private conversation while in the Nursing Facility.

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of one resident (#911) to be free from physical abuse by another resident. The deficient practice could result in further abuse of residents and appropriate action not taken.Findings include: -Resident #911 (alleged victim) was admitted to the facility on [DATE] with diagnoses of aphasia, hemiplegia, hemiparesis, dementia, major depressive disorder, and anxiety disorder. A physician order dated January 17, 2025 indicated for resident to reside on secured unit due to vascular dementia. Review of the psycho-social/trauma care plan revised on January 14, 2026 revealed the resident was at risk for psycho-social well-being problem related to dementia with behaviors, anxiety and history of substance abuse. The care plan noted that the resident was involved in an altercation with another resident on January 12, 2026. The goal set was that resident will minimize risk for psychosocial well-being problem. Interventions included to offer emotional support, calm reassurance, provide activities with increased 1:1, monitor any changes in mood or behaviors status post incident, and to notify Social Services and Behavioral Health team if any adverse changes occur. A cognition care plan revised on January 14, 2026 indicated that the resident was at risk for cognitive problems and abuse related to dementia. The goal set was for resident to develop skills to cope with cognitive decline and maintain safety. Interventions indicated included offer emotional support, give calm reassurance, provide activities with increased 1:1, monitor for any changes in mood or behavior status post incident, and notify Social Services and Behavioral Health if any adverse changes occur. Review of the significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had both short and long-term memory problems. The assessment indicated that the resident had moderate cognitive impairment regarding daily decision making. Further review of the MDS assessment dated [DATE] indicated that the resident exhibited both physical and verbal behavioral symptoms directed towards others between 1-3 days during the assessment period. Per the MDS the resident exhibited wandering behavior 1-3 days during the assessment period. Review of the facility's Incident Report (with an unreadable date) pertaining to resident #911 documented a resident to resident altercation noted as Physical Aggression Received. The incident location was identified as the hallway. Per the report a staff member witnessed another resident (room [ROOM NUMBER]B occupant) suddenly rise from his wheelchair and struck resident #911 twice on the nose with a closed fist. The report noted that resident #911 sustained small, open, bleeding area across the bridge of the nose. Resident #911 was assessed with 5/10 pain scale. The provider was notified and an order was received for a stat x-ray and to send the resident to the ER (Emergency Room) to rule out a broken nose. A Radiology Interpretation report dated January 12, 2026 revealed that that resident's nasal bones and adjacent soft tissues were intact. Similarly, the frontal and maxillary sinuses as well as the skull and facial bones were normal. A Wound Care note dated January 12, 2026 documented that the resident had a new skin condition. Review of a Skin assessment dated [DATE] documented that the resident had an abrasion on the bridge of the nose. A Nurses Notes dated January 13, 2026 stated that at 6:00 p.m. (the incident is presumably the day before based on note's timestamp) a staff witnessed the resident sitting in his wheelchair when another resident (identified as room [ROOM NUMBER]B) approached him and punched resident #911 on the nose twice with a closed fist. The note documented that resident #911 sustained a small, open, bleeding area across the bridge of the nose. According to the note, the provider was notified and an order was received to send resident #911 to the ER via ambulance. Due to the 6-hr ambulance pick-up wait, the provider was informed and an order for a stat inhouse x-ray for the resident's nose was received. Results from the x-ray revealed normal facial and nasal bone. A Social Services Note dated January 13, 2026 documented a psycho-social evaluation. The note indicated that Social Services met with the resident following a resident to resident altercation which occurred the evening prior. According to the note the resident appeared to be passively complaint, calm, and without observable signs of distress. The note stated that the resident demonstrated limited verbal communication. The resident primarily responded by nodding or providing brief, simple statements. The note indicated that the resident recalled the incident and said he was okay. The note documented that for safety and monitoring purposes, nursing staff will continue to observe the resident, and psychosocial follow-up will occur as clinically indicated. An IDT (Interdisciplinary Team) Note dated January 14, 2026 indicated that the team met to review the incident which occurred on January 12, 2026 related to a physical altercation between residents. The note stated that resident #911 resides in a secured behavioral unit. The resident has diagnoses of dementia with behavioral disturbances and major depressive disorder. Per the note a staff witnessed another resident approach and struck resident #911 on the nose. According to the note the interventions implemented were: Resident #911 offered emotional support, provided calm reassurance, aggressor was placed on 15-minute checks for 3-days. Furthermore, the note indicated that staff would monitor for any changes in mood or behavior status post incident, notify Social Services, and Behavioral Health team if any adverse changes occur. Review of a Nurses Note dated January 15, 2026 documented that bruising on the resident's right eye was noted status post altercation from January 12, 2026. Per the note, resident's abrasion on the nose showed no signs of infection. A Psych Follow Up note dated January 15, 2026 indicated that resident was seen for routine psychiatric follow-up. According to the note, the resident's safety was assessed and deemed current risk to be low. Additionally, the note indicated that a safety plan was not required. The note revealed no indication that the resident-to-resident altercation was discussed. A subsequent Nurses Note also dated January 15, 2026 documented bruising to the right eye persisted. The note indicated that there was no signs or symptoms of infection regarding the nose abrasion. A Physician Progress Notes dated January 16, 2026 documented that resident was punched in face by other resident. The note indicated that x-ray was negative but that there was residual bruising and small laceration on the nose which was healing well. -Resident #999 (alleged perpetrator) was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia, anxiety disorder schizophrenia, psychosis, and major depressive disorder. A care plan initiated on May 6, 2024 revealed that the resident was placed in a secured unit due to diagnoses of psychosis, and schizophrenia with behaviors such as verbal and physical aggression towards staff. The identified goal was for resident to remain safe and meet all needs. Interventions indicated for behavioral health services to evaluate and treat if indicated, cares in pairs, document all behaviors, and notify medical/psychiatric provider with updates as needed. A care plan revised on January 15, 2025 documented that the resident required cares in pairs due to physical aggression towards others. Interventions directed for two staff members to care for the resident at all times and notify psych/medical providers with updates as needed. A Nursing Note dated October 28, 2025 documented that the resident hit another resident on the nose. The note indicated that resident #999 stated that the other resident kicked his wheelchair three times so he got up and punched him. The note indicated that resident #999 stated They deserve it, I take care of my wheelchair. Per the note the resident was moved to another unit. However, review of the clinical record did not reveal that the incident on October 28, 2025 was addressed in a care plan with identified interventions to prevent further incidents. A subsequent Nursing Note also dated October 28, 2025 indicated that resident was transferred to unit C1. A Nurses Notes dated November 1, 2025 documented that as a Certified Nursing Assistant (CNA) was assisting the resident put his belt on following a brief change, the resident hit the hand of the CNA, was verbally aggressive, cussed out the CNA in Spanish language, and threw the bedside commode. However, review of the clinical record did not reveal that the incident on November 1, 2025 was addressed in a care plan with identified interventions to prevent further incidents. A behavioral care plan initiated on December 12, 2025 documented that resident had a behavior problem which included combative behavior, and aggressive behaviors such as yelling, hitting, and grabbing. The goals identified were for resident to not have evidence of behavior problems and have fewer episodes of physical aggression. Interventions included to anticipate/meet needs, monitor behavior episodes and attempt to determine underlying cause, administer medications as ordered, intervene as necessary to protect the rights and safety of others, and remove from situation/take to alternate location as needed. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) score of 10 indicating that the resident had moderate cognitive impairment. The MDS also noted that the resident had no indicators of psychosis and behavioral symptoms directed towards others at the time of the assessment period. Review of the facility's Incident Report dated January 12, 2026 pertaining to resident #999 revealed a resident to resident altercation noted as Physical Aggression Initiated. The incident location was identified as the hallway. The report documented that a staff witnessed resident #999 walk over to another resident (room [ROOM NUMBER]A occupant) and punched that resident on the nose with a closed fist twice. Per the report there was no injury noted on resident #999. The residents were immediately separated following the incident. The report indicated that resident #999 went into his room and slammed his door shut. The report stated that according to resident #999, he punched the other resident on the face because that resident grabbed his GF's (girlfriend) hand. The report noted that the girlfriend was nowhere in the hall when the incident happened. A revised behavioral care plan dated January 13, 2026 noted that the resident had physical aggression on January 12, 2026 in which he hit another resident. The goal identified were for resident to have fewer episodes of physical aggression, and not have evidence of behavior problems. Interventions noted indicated that resident was placed on 15-minute checks three times a day, referred for alternative high-acuity Behavioral Health placement, psych follow-up, and new medication was prescribed/started. A Nurses Notes dated January 13, 2026 documented that at 6:00 p.m. (presumably the day before given the timestamp of the note) staff witnessed resident #999 approach another resident and punched that resident on the nose with a closed fist twice. The residents were separated immediately. Per the note resident #999 appeared to not have sustained any injury to his hand. Resident #999 then went into his room and slammed his door shut. The note indicated that resident #999 informed staff that he punched the other resident in the face because that resident grabbed resident #999's girlfriend's hand. According to the note, the girlfriend was nowhere in the hallway when the incident occurred. A Social Services Note dated January 13, 2026 documented a Psycho-Social Evaluation which took place following an altercation with another resident the evening before. Per the note the resident was able to recall the incident and stated He was trying to touch my girlfriend. The note indicated that resident #999 laughed while he recounted the altercation. According to the note the IDT (Interdisciplinary Team) discussed the incident with the resident and attempted family contact to explore potential transfer to an alternate facility due to safety concerns. The note stated that that in response to the incident, nursing staff would continue frequent safety checks, and a room change was initiated to support resident and unit safety. However, review of the resident's clinical census revealed that the resident had remained in the same room he was assigned since October 28, 2025 up until his discharge on [DATE]. Review of an IDT Note dated January 14, 2026 documented that the IDT met to review the incident on January 12, 2026 involving a physical altercation with another resident. Per the note resident #999 resided in a secured Behavioral Health unit. Based on witnessed event, the interventions implemented were to place resident on 15-minute checks three times a day, refer for placement to an alternative high-acuity Behavioral Health, psych follow-up, and new medication was prescribed/started. A Nurses Notes dated January 14, 2026 documented that resident was discharged to another facility. Review of the facility's Facility Reported Incident Form Follow-up Report dated January 15, 2026 documented an investigation pertaining to an incident involving residents #911 and #999. The investigation revealed that an oncoming shift's nurse witnessed resident #999 get up from his wheelchair and walk towards resident #999 and struck him on the nose. The report included interviews of both the alleged victim (resident #911), alleged perpetrator (resident #999) and witness (staff #98) statement. The report noted that according to resident #999, he became upset after he observed a friend's hand touched by resident #911. This caused resident #999 to react. Per the witness statement (staff #98), as she walked through the double doors of the unit, she saw resident #999 approach resident #911 who was sitting in his wheelchair and punched resident #911 on the nose twice with a closed fist. The investigation report concluded that the allegation of abuse was verified. An interview with a Certified Nursing Assistant (CNA/staff #166) was conducted on January 26, 2026 at 2:51 p.m. The CNA stated that she was not present when the incident occurred but heard that it had gotten physical between residents #911 and #999. The CNA said that resident #911 sustained a blackeye and a cut on his nose as a result of that altercation but that the injuries has healed. Per the CNA the incident was inappropriate and that resident #999's actions would be categorized as abuse. The CNA noted that to her knowledge the incident was unprovoked and commented that resident #999 had triggers. According to the CNA it is important for residents to not be subjected to abuse because the residents have rights. Additionally, the facility is responsible for the residents' care and dignity-part of that is to be free from abuse. The CNA stated that the potential impact of abuse is that residents could end up depressed, scared, withdrawn, and not trust others. In the case of resident #911 (alleged victim) the impact is not noticed because he does not fully understand what happened so he is essentially back to normal. During an interview with a Registered Nurse (RN/staff #99) conducted on January 26, 2026 at 3:03 p.m., the RN stated that in the behavior unit they have to closely monitor residents' safety and ensure that there are no incidents. Some residents have triggers so they are monitored to ensure they can prevent triggers that can affect other residents. According to the RN a physical altercation is abuse. The RN noted that it is important that residents are not subjected to abuse because their safety is a priority, the facility is tasked with caring for the residents/meeting the residents needs, and preventing abuse from happening. The RN said that if a resident is subjected to abuse, it affects them physically, emotionally, mentally, and they can be hurt and it affects their mind. Per the RN, she was informed that approximately two weeks ago, resident #999 punched resident #911 on the face. As a result of the incident resident #999 was transferred to another facility. The RN noted that she was told that resident #911 sustained a bruise on his eye and a cut on his nose. The injuries had since resolved. An x-ray was taken and no fractures were noted. The RN said that resident #999 had known behaviors and was aggressive. The RN shared that resident #999 have previously hit a CNA approximately 1 1/2 month ago and that the CNA sustained a bruise. An interview with the Director of Social Services (Dir SS/staff #60) was conducted on January 28, 2026 at 10:38 a.m. The Dir SS stated that the impact of a resident being subjected to abuse is that the potential that the resident is placed in danger and that resident and others would not be safe. Staff #60 stated that she was not familiar with the incident between residents #911 and #999. However, the Dir SS noted that resident #999 was the instigator in most of the incidents he was involved in. Staff #60 said that the facility spoke with resident #999's family about the incident but the family was not helpful and laughed about the incident. Due to this most recent incident it was decided that resident #999 be transferred to another facility. An interview with the Director of Nursing (DON/staff #25) was conducted on January 28, 2026 at 2:29 p.m. Staff #25 stated that it is important that residents are not subjected to abuse because the residents are in the facility for care, and to get their health condition managed. Therefore, the residents' safety, dignity, and rights are important. The DON said that impact of abuse is that the resident can get scared, depressed, be on guard, and lead to care refusal. The DON stated that it is not good for a resident to experience abuse since no one can give the resident a sense of safety except for staff. The DON said that with regards to the altercation between residents #999 and #911, the investigation revealed that the alleged victim was sitting and the aggressor punched him on the nose. The DON noted that per the investigation the incident was verified as a resident to resident altercation. The facility policy on Abuse and Neglect adopted May 1, 2024 revealed that it is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse. Per the policy the prevention of abuse includes the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict such as residents with history of aggressive behaviors. A facility policy titled Quality of Care Accident Hazards/Supervision/Devices dated July 2018 stated that the facility recognizes that resident-to-resident altercations could be a situation of abuse. The policy noted that reasonable precautions will be taken when the risk of resident-to-resident altercation is present. Additionally, the facility will identify residents who exhibit behavior that make them more likely to be involved in an altercation. Furthermore, interventions will be implemented to minimize or control incidents of disruptive or intrusive behavior to minimize altercations.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#333) to be free from financial misappropriation/exploitation of resident property by another resident (#111). The deficient practice could result in further financial abuse of residents when appropriate actions are not taken.-Regarding Resident #111 (alleged perpetrator):Resident #111 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder, obesity, and life management difficulty.Review of the care plan dated August 19, 2023, revealed that the resident has psychological aspects of chronic illness. The interventions included providing the Resident/Representative a list of community resources, and identifying the disease progression and when to notify the health care provider.A care plan dated October 25, 2023, revealed the resident has a history of self-harmful ideation (thoughts) and/or behaviors. The problems/needs are manifested by: sharing thoughts of self-harm when interviewed; and the ideation appears related to: poor impulse control. The interventions included to assess what and where it occurred, assess the circumstances surrounding the event, assess any precipitants and any current plan to harm; and establish a safety contract (verbal and/or written) with the resident.A review of the Resident's annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating that the resident was cognitively intact. The resident did not exhibit behavioral symptoms.A review of the administrative progress note dated October 29, 2024, revealed that the staff notified the health plan of a 30-day notice, and requested assistance with placement.On December 3, 2024, per the nursing progress note document, Resident #111 was discharged to another facility.-Regarding Resident #333 (alleged victim):Resident #333 was admitted to the facility on [DATE], with diagnoses that included anemia, chronic obstructive pulmonary disease (lung disease that causes difficulty breathing and chronic cough), weakness, and major depressive disorder.On August 20, 2024, the use of antidepressant medication related to the depression care plan was initiated. The interventions included to give antidepressant medications ordered by physician, monitor for side effects and effectiveness which include dry mouth, dry eyes, constipation, urinary retention, suicidal ideations; and monitor for ongoing signs and/or symptoms of depression unaltered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, or does not enjoy usual activities.A review of the Resident's quarterly MDS assessment dated [DATE], revealed a BIMS score of 13.0, indicating that the resident was cognitively intact.Review of the Resident's care plan dated October 22, 2024, revealed a potential risk for alteration in mood state and psychosocial well-being. The interventions included observing and reporting any changes in mental status/behaviors caused by situational stressors, and provide opportunities to express feelings related to these stressors.The nurses' progress note dated October 26, 2024, revealed per documentation that Resident #333 was placed on every 15-minute check since the day before. A cop was in the Resident's room for 30 minutes, and then the cop met with the social service after talking to Resident #333.A review of a nurse practitioner's progress notes dated October 28, 2024, revealed that Resident #333 was still upset about the encounter with a fellow resident being robbed. Resident #333 had spoken with the detectives and a few hours later, Resident #333 was experiencing some chest pain. Per documentation, Resident #333 felt better later and the pain had resolved; Resident #333 had increased anxiety and sadness and wants to move to another facility; and the social service was involved in finding a new facility for Resident #333.On January 6, 2025, per documentation from the nurse practitioner's progress notes, Resident #333 was cleared to be discharged from the hospital but Resident #333 refused to return back to the facility.A review of the facility's incident follow-up report dated October 25, 2024, revealed that the names of the residents involved were not included in the report. Resident reported the incident to the director of nursing (DON), Business Office Manager (BOM), and social service director (SSD) regarding the alleged event. Perpetrator was interviewed by the DON, BOM, and the SSD. After the initial interview, the interdisciplinary team (IDT) completed a thorough investigation, which included an outreach to the police, APS (Adult Protective Services), and the ombudsman. The report revealed that the perpetrator reported that she assisted the victim with her funds, and the victim gave permission to use the funds, and then the perpetrator continued to use them without the victim's permission. Further, the report revealed that during interviews, it was not reported that staff had any knowledge that the victim had provided the perpetrator access to her funds until she reported the event. The facility verified the allegation. The report also included corrective action taken. The perpetrator was on frequent checks, and the perpetrator was given a 30-day notice to vacate the facility with the assistance from the SSD.A self-report for October 2024 involving Resident #333 was requested during the onsite survey. A review of the document provided by the administrator (Staff #87) on January 28, 2026, at 7:15 AM, revealed no self-report in October 2024 regarding Resident #333.An interview was conducted on January 28, 2026, at 8:28 AM with the business office manager (BOM/Staff #44). She stated that her responsibility included conducting interviews for residents applying for Arizona Long Term Care Services (ALTCS). Regarding Resident #333, she said that the resident handled her own finances, and the resident befriended Resident #111, whom Resident #333 met during bingo. She said that around October 2024, Resident #111 started stealing money from Resident #333. She said that Resident #333 gave her debit card and some cash to Resident #111 to hold for her. She said that Resident #111 used the money to buy clothes for herself and clothes for Resident #333. She also said that Resident #111 also purchased coins for virtual slot games. Further, she said that she found out about the incident when Resident #333 spoke to her. She stated that the social service director (Staff #60) conducted an investigation; the DON, the Arizona Department of Health (AzDHS), and the police were notified; and a police report was filed. Furthermore, she said that Resident #111 was confronted by a private investigator, Resident #111 was served a summon to see a judge, and Resident #111 was also transferred out to another facility. She stated that Resident #333 cancelled her debit card and was transferred out of the facility. She said that the administrator was not informed of the incident because the facility did not have an administrator in October. Regarding her abuse training, she said that abuse is when someone is taking advantage of another person in any way such as financially, physically, sexually, emotionally, and the person has no means to defend themselves. She said that financial abuse is when someone is taking advantage of a person's finances that cannot fight back. She said that she considered the incident between Resident #333 and Resident #111 an abuse because Resident #111 was much younger than Resident #333. She also stated that if she witnessed or was made aware of any abuse, her responsibility is to notify the administrator, call the police, speak to the victim, and call Adult Protective Services (APS). She will notify the administrator to make them aware of the allegation of abuse because it is everyone's responsibility to protect every resident. She said that Resident #333 wanted the police to be notified and Resident #111 arrested. She said that she does not have any documentation regarding the incident, and she only has the investigator's card, but the social service director (Staff #60) might have the documentation.An interview was conducted on January 28, 2026 at 8:50 AM with the social service director (SSD/Staff #60). The social service director stated that she conducts psychosocial interviews with her residents to assess their cognitive assessment (BIMS score), mood interview (PHQ9), trauma evaluation for life event checklist, assess behaviors in MDS, and discharge planning. Regarding Resident #333, the social worker director stated that she notified the APS about Resident #111, who was Resident #333's roommate. She said that Resident #333 at first consented for her Resident #111 using her finances, but later found out that Resident #111 was using Resident #333's debit card. The social service director stated that the way she found out about the incident was when Resident #111 was not paying her share of the cost to the facility. She stated that she noticed boxes of purchases in Resident #111's room. She said that she notified APS; separated Resident #333 and Resident #111 by changing their rooms; and she helped Resident #333 report the fraud and get her a new card. She stated that she reported the incident to the DON (Staff #193), APS, and the ombudsman. She stated that the DON was in communication with the acting administrator (Staff #194) at that time. She stated that Staff #194 reported the incident to Arizona Department of Health Services. Regarding Resident #111, she said that Resident #111 was moved to another room and was given a 30-day notice to vacate for the safety of the other residents, and Resident #111 transferred to another facility on December 3, 2024. Regarding her abuse training, she stated that abuse is verbal, financial, sexual, physical, emotional, and anything that places a resident in harm or potential harm. She stated that financial abuse is when somebody's finances are exploited. She said that the incident between Resident #333 and Resident #111 was financial exploitation.An interview was conducted on January 28, 2026, at 9:27 AM with the administrator (Staff #87). Regarding Resident #333, the administrator stated that she had no knowledge about this incident because the incident happened before she was employed by this facility. She said that she was made aware of this resident-to-resident misappropriation of property incident yesterday. She also stated that she was unable to find the reportable event, and she is still searching for the report. The administrator also stated that the reportable should be a record of the event, and the investigation should be saved on paper or electronically in the facility for availability for review.Attempted to interview Resident #333 telephonically on January 28, 2026, at 11:09 AM, but it was unsuccessful.An interview was conducted on January 28, 2026, at 3:57 PM with a certified nursing assistant (CNA/Staff #69). Staff #69 stated that misappropriation would fall under abuse. She stated that the impact of misappropriation would affect the resident badly, especially if the resident was coherent and taken advantage of, and it is unfair. She stated that she was not familiar with Resident #333 and Resident #111.An interview was conducted on January 28, 2026, at 4:08 PM with a licensed practical nurse (LPN/Staff #85) regarding financial misappropriation. Staff #85 stated that misappropriation is a crime. She said that nobody wants that to happen; when a resident arrives in the facility with money, the money is counted, but is otherwise taken to the business office. Staff #85 remembered an incident that happened 2 years ago involving Resident #333. Staff #85 stated that Resident #333's money was being taken; Resident #333 befriended and was very close to Resident #111, who was a lot younger and was in a different unit. Staff #85 said that Resident #111 was among the leaders of the resident council, so Resident #111 was easily trusted; Resident #333 was older so Resident #111 would visit Resident #333 in her room and hang out; and Resident #333 and Resident #111 hung out in each other's room. Staff #85 stated that all of a sudden, Resident #333 reported that her money was being stolen; Resident #111 would use Resident #333's card and go online shopping; Resident #333 realized that her money was being stolen, and it was reported. Staff #85 said that Resident #111 got in trouble, the police and APS got involved, and Resident #111 ended up in another facility. Staff #85 stated that the incident changed Resident #333's demeanor and started secluding herself. Staff #85 remembered Resident #333 telling him My friend disappointed me; Resident #333 was depressed, stopped doing activities, and shortly after that, Resident #333 was sent out to the hospital and she did not want to come back.Review of facility policy titled Abuse and Neglect, adopted on May 1, 2024, revealed that it is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. If abuse is suspected the facility will conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to maintain documentation that an alleged violation related to the allegation of financial misappropriation of property for one resident (#333) by another resident (#111) was thoroughly investigated. The deficient practice could result in further financial abuse of residents when appropriate actions are not taken.-Regarding Resident #111 (alleged perpetrator):Resident #111 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder, obesity, and life management difficulty.Review of the care plan dated August 19, 2023, revealed that the resident has psychological aspects of chronic illness. The interventions included providing the Resident/Representative a list of community resources, and identifying the disease progression and when to notify the health care provider.A care plan dated October 25, 2023, revealed the resident has a history of self-harmful ideation (thoughts) and/or behaviors. The problems/needs are manifested by: sharing thoughts of self-harm when interviewed; and the ideation appears related to: poor impulse control. The interventions included to assess what and where it occurred, assess the circumstances surrounding the event, assess any precipitants and any current plan to harm; and establish a safety contract (verbal and/or written) with the resident.A review of the Resident's annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating that the resident was cognitively intact. The resident did not exhibit behavioral symptoms.A review of the administrative progress note dated October 29, 2024, revealed that the staff notified the health plan of a 30-day notice, and requested assistance with placement.On December 3, 2024, per the nursing progress note document, Resident #111 was discharged to another facility.-Regarding Resident #333 (alleged victim):Resident #333 was admitted to the facility on [DATE], with diagnoses that included anemia, chronic obstructive pulmonary disease (lung disease that causes difficulty breathing and chronic cough), weakness, and major depressive disorder.On August 20, 2024, the use of antidepressant medication related to the depression care plan was initiated. The interventions included to give antidepressant medications ordered by physician, monitor for side effects and effectiveness which include dry mouth, dry eyes, constipation, urinary retention, suicidal ideations; and monitor for ongoing signs and/or symptoms of depression unaltered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, or does not enjoy usual activities.A review of the Resident's quarterly MDS assessment dated [DATE], revealed a BIMS score of 13.0, indicating that the resident was cognitively intact.Review of the Resident's care plan dated October 22, 2024, revealed a potential risk for alteration in mood state and psychosocial well-being. The interventions included observing and reporting any changes in mental status/behaviors caused by situational stressors, and provide opportunities to express feelings related to these stressors.The nurses' progress note dated October 26, 2024, revealed per documentation that Resident #333 was placed on every 15-minute check since yesterday. A cop was in the Resident's room for 30 minutes, and then the cop met with the social service after talking to Resident #333.A review of a nurse practitioner's progress notes dated October 28, 2024, revealed that Resident #333 was still upset about the encounter with a fellow resident being robbed. Resident #333 had spoken with the detectives and a few hours later, Resident #333 was experiencing some chest pain. Per documentation, Resident #333 felt better later and the pain had resolved; Resident #333 had increased anxiety and sadness and wants to move to another facility; and the social service was involved in finding a new facility for Resident #333.On January 6, 2025, per documentation from the nurse practitioner's progress notes, Resident #333 was cleared to be discharged from the hospital but Resident #333 refused to return back to the facility.A review of the facility's incident follow-up report dated October 25, 2024, revealed that the names of the residents involved were not included in the report. Resident reported the incident to the director of nursing (DON), Business Office Manager (BOM), and social service director (SSD) regarding the alleged event. Perpetrator was interviewed by the DON, BOM, and the SSD. After the initial interview, the interdisciplinary team (IDT) completed a thorough investigation, which included an outreach to the police, APS (Adult Protective Services), and the ombudsman. The report revealed that the perpetrator reported that she assisted the victim with her funds, and the victim gave permission to use the funds, and then the perpetrator continued to use them without the victim's permission. Further, the report revealed that during interviews, it was not reported that staff had any knowledge that the victim had provided the perpetrator access to her funds until she reported the event. The facility verified the allegation. The report also included corrective action taken. The perpetrator was on frequent checks, and the perpetrator was given a 30-day notice to vacate the facility with the assistance from the SSD. However, the facility's incident follow-up report dated October 25, 2024, did not include interview statements from staff members or other residents who might have interactions with Resident #333 and Resident #111.A self-report for October 2024 involving Resident #333 was requested during the onsite survey. A review of the document provided by the administrator (Staff #87) on January 28, 2026, at 7:15 AM, revealed no self-report in October 2024 regarding Resident #333.An interview was conducted on January 28, 2026, at 8:28 AM with the business office manager (BOM/Staff #44). She stated that her responsibility included conducting interviews for residents applying for Arizona Long Term Care Services (ALTCS). Regarding Resident #333, she said that the resident handled her own finances, and the resident befriended Resident #111, whom Resident #333 met during bingo. She said that around October 2024, Resident #111 started stealing money from Resident #333. She said that Resident #333 gave her debit card and some cash to Resident #111 to hold for her. She said that Resident #111 used the money to buy clothes for herself and clothes for Resident #333. She also said that Resident #111 also purchased coins for virtual slot games. Further, she said that she found out about the incident when Resident #333 spoke to her. She stated that the social service director (Staff #60) conducted an investigation; the DON, the Arizona Department of Health (AzDHS), and the police were notified; and a police report was filed. Furthermore, she said that Resident #111 was confronted by a private investigator, Resident #111 was served a summon to see a judge, and Resident #111 was also transferred out to another facility. She stated that Resident #333 cancelled her debit card and was transferred out of the facility. She said that the administrator was not informed of the incident because the facility did not have an administrator in October. Regarding her abuse training, she said that abuse is when someone is taking advantage of another person in any way such as financially, physically, sexually, emotionally, and the person has no means to defend themselves. She said that financial abuse is when someone is taking advantage of a person's finances that cannot fight back. She said that she considered the incident between Resident #333 and Resident #111 an abuse because Resident #111 was much younger than Resident #333. She also stated that if she witnessed or was made aware of any abuse, her responsibility is to notify the administrator, call the police, speak to the victim, and call Adult Protective Services (APS). She will notify the administrator to make them aware of the allegation of abuse because it is everyone's responsibility to protect every resident. She said that Resident #333 wanted the police to be notified and Resident #111 arrested. She said that she does not have any documentation regarding the incident, and she only has the investigator's card, but the social service director (Staff #60) might have the documentation.An interview was conducted on January 28, 2026 at 8:50 AM with the social service director (SSD/Staff #60). The social service director stated that she conducts psychosocial interviews with her residents to assess their cognitive assessment (BIMS score), mood interview (PHQ9), trauma evaluation for life event checklist, assess behaviors in MDS, and discharge planning. Regarding Resident #333, the social worker director stated that she notified the APS about Resident #111, who was Resident #333's roommate. She said that Resident #333 at first consented for her Resident #111 using her finances, but later found out that Resident #111 was using Resident #333's debit card. The social service director stated that the way she found out about the incident was when Resident #111 was not paying her share of the cost to the facility. She stated that she noticed boxes of purchases in Resident #111's room. She said that she notified APS; separated Resident #333 and Resident #111 by changing their rooms; and she helped Resident #333 report the fraud and get her a new card. She stated that she reported the incident to the DON (Staff #193), APS, and the ombudsman. She stated that the DON was in communication with the acting administrator (Staff #194) at that time. She stated that Staff #194 reported the incident to Arizona Department of Health Services. Regarding Resident #111, she said that Resident #111 was moved to another room and was given a 30-day notice to vacate for the safety of the other residents, and Resident #111 transferred to another facility on December 3, 2024. Regarding her abuse training, she stated that abuse is verbal, financial, sexual, physical, emotional, and anything that places a resident in harm or potential harm. She stated that financial abuse is when somebody's finances are exploited. She said that the incident between Resident #333 and Resident #111 was financial exploitation.An interview was conducted on January 28, 2026, at 9:27 AM with the administrator (Staff #87). The administrator stated that her responsibilities included overseeing regulatory compliance, facility operations, resident satisfaction, quality care, and resident mediation. Regarding an allegation of abuse, the administrator stated that abuse is physical, mental, sexual, financial, and technological. She said that she does not permit abuse; abuse will be addressed promptly, investigated, and the investigation will be reported to the Arizona Department of Health Services, police, ombudsman, and the Adult Protective Services. The administrator stated that the abuse investigation process depends on the type; if it involves a staff member, the staff member will be removed from the work environment; she will interview residents and staff members; conduct a skin assessment; may order a behavioral health assessment; and she will look at the environment, if applicable. She said that once she has the relevant information, their interdisciplinary team will assess all the information gathered, form a conclusion, put an intervention in place to protect the residents and ensure their safety. Once all information is gathered, she and her team will determine whether the allegation was verified. Then, she will turn the final investigation report to the department of health services; continue to monitor the resident; appropriately implement the interventions to care for the resident, and if necessary, terminate the employee, and report the employee to the state if verified. She also said that she will investigate to make sure that the resident was provided care appropriately and ensure quality care to residents. Further, she reports the allegation of abuse to the agencies because it is mandatory, and it is a way to ensure that employees will not be able to work in other places and abuse other vulnerable adults in other communities. Further, the administrator stated that the impact of an investigation of an abuse not being done could continue the abuse and impact the quality of care. She stated that the impact of not reporting the allegation of abuse to agencies could be a violation against regulations. Regarding Resident #333, the administrator stated that she had no knowledge about this incident because the incident happened before she was employed by this facility. She said that she was made aware of this resident-to-resident misappropriation of property incident yesterday. She also stated that she was unable to find the reportable event, and she is still searching for the report. The administrator also stated that the reportable should be a record of the event, and the investigation should be saved on paper or electronically in the facility for availability for review.Attempted to interview Resident #333 telephonically on January 28, 2026, at 11:09 AM, but it was unsuccessful.An interview was conducted on January 28, 2026, at 3:57 PM with a certified nursing assistant (CNA/Staff #69). Staff #69 stated that misappropriation would fall under abuse. She stated that the impact of misappropriation would affect the resident badly, especially if the resident was coherent and taken advantage of, and it is unfair. She stated that she was not familiar with Resident #333 and Resident #111.An interview was conducted on January 28, 2026, at 4:08 PM with a licensed practical nurse (LPN/Staff #85) regarding financial misappropriation. Staff #85 stated that misappropriation is a crime. She said that nobody wants that to happen; when a resident arrives in the facility with money, the money is counted, but is otherwise taken to the business office. Staff #85 remembered an incident that happened 2 years ago involving Resident #333. Staff #85 stated that Resident #333's money was being taken; Resident #333 befriended and was very close to Resident #111, who was a lot younger and was in a different unit. Staff #85 said that Resident #111 was among the leaders of the resident council, so Resident #111 was easily trusted; Resident #333 was older so Resident #111 would visit Resident #333 in her room and hang out; and Resident #333 and Resident #111 hung out in each other's room. Staff #85 stated that all of a sudden, Resident #333 reported that her money was being stolen; Resident #111 would use Resident #333's card and go online shopping; Resident #333 realized that her money was being stolen, and it was reported. Staff #85 said that Resident #111 got in trouble, the police and APS got involved, and Resident #111 ended up in another facility. Staff #85 stated that the incident changed Resident #333's demeanor and started secluding herself. Staff #85 remembered Resident #333 telling him My friend disappointed me; Resident #333 was depressed, stopped doing activities, and shortly after that, Resident #333 was sent out to the hospital and she did not want to come back.Review of facility policy titled Abuse and Neglect, adopted on May 1, 2024, revealed that it is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. If abuse is suspected the facility will conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one resident (#191), which provides instructions to meet the resident's immediate needs. The deficient practice could result in resident's treatments and needs not appropriately addressed.Findings Include:Resident #191 was readmitted to the facility on [DATE], with diagnoses that included rhabdomyolysis (is a rare muscle injury where your muscles break down), adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit.A review of the Clinical admission Evaluation progress note dated August 3, 2024, revealed that the resident's admission mode was wheelchair. The Resident was alert and oriented times 3; alert (some forgetfulness).A physician-admission history and physical progress note dated August 3, 2024, revealed per documentation that resident was in a medical center with a 2- day history of weakness and falls at home, unable to ambulate with associated dizziness.An admission Morse Fall Scale Evaluation dated August 3, 2024, revealed a score of 65.0, indicating resident was assessed for high risk for falling.Review of the resident's medical record revealed no baseline care plan developed within 48 hours of the resident's admission.A review of the comprehensive care plan dated August 5, 2024, revealed that the resident had an activities of daily living self-care performance deficit related to deconditioning; the resident was at risk for falls related to deconditioning and gait/balance problems. The interventions initiated on August 5, 2024 included to encourage the resident to participate to the fullest extent possible with each interaction; encourage the resident to use bell to call for assistance; anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; the resident needs prompt response to all requests for assistance; and ensure commonly used items (ice water, glasses if applicable, call light, phone, remote) are within reach of resident prior to leaving room.On August 6, 2024, a Daily Skilled Charting progress note revealed per documentation, gait during shift-unsteady; poor balance during shift; bedfast all or most of the time during shift; the resident is sometimes displaying untoward behaviors; she refused to follow instructions; she insisted on doing her own; and she insisted on going to the bathroom even if she has briefs on.Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score 6.0, indicating that the resident's cognition was severely impaired.On August 9, 2024, a nurses' progress note revealed per documentation, that the resident was seen sitting on the floor with back leaning on the side of the bed and both legs extended. The Resident claimed that she slipped slowly while trying to stand up to go to the bathroom. The resident was assessed, no noted bruises or skin tear; resident was assisted back to bed; kept bed on lowest level for safety; neuro check was started; provider, assistant director of nursing, emergency contact were notified; put back non-slipped socks; reinstructed to use call light for assistance; and fall prevention signage was placed on the resident's room.Review of the Neurological Flow Sheet revealed a neuro check was completed on August 8, 2024, through August 13, 2024. The results of the neuro checks revealed that Resident #191 was fully conscious, her pupils' reaction was brisk, her speech was clear, she moved all of her 4 extremities equally and strong, and the Resident's vital signs were also monitored.On August 13, 2024, a nurses' progress note revealed per documentation resident was found lying on the floor; resident verbalized she did not hit her head; vital signs taken; neuro check started; no verbalized pain; resident was advised to use walker when ambulating; walker was placed at reach for use; bed was placed at the lowest position for safety; the provider, assistant director of nursing (ADON), were notified and resident's emergency contact cannot be reached.Review of the Neurological Flow Sheet revealed a neuro check was completed on August 13, 2024 through August 16, 2024. The result of the neuro checks revealed that Resident #191 was fully conscious, her pupils' reaction was brisk, her speech was clear, she moved all of her 4 extremities equally and strong, and the Resident's vital signs were also monitored.On August 16, 2024, a nurses 'progress note revealed per documentation, the incident was unwitnessed fall; resident was seen on the floor, on prone position; forehead laceration bleeding and was controlled; left knee skin tear; resident cannot verbalize what had happened prior to fall; she appears to be confused; resident was assessed; neuro check initiated; resident was able to verbalized pain over the affected area; 911 called; resident was transferred out to the hospital; and management, provider, and emergency contact were notified.An interview was conducted on January 28, 2026, at 8:32 AM with a certified nursing assistant (CNA/Staff #148). Staff #148 stated that fall risk was discussed with the new admission. Staff #148 stated that for a fall risk resident, the mattress is placed at the side of the bed; she is instructed to lower the bed; and when the resident arrived from the hospital, the resident have a fall risk tag. Staff #148 stated that it was important to monitor the resident closely because the impact of residents not being monitored is that they can have a fracture, or be afraid to do things after a fall, lose confidence, and get hurt.An interview was conducted with a licensed practical nurse (LPN/Staff #85) on January 28, 2026 at 9:05 AM. Regarding fall, Staff #85 stated that staff can move resident closer to the nurses' station, have call light, increase safety checks; maybe have a fall mattress. Staff #85 stated that fall has a lot of risk such as broken bones, injuries and hospitalization.An interview was conducted on January 28, 2026, at 3:31 PM with a Registered Nurse (RN/Staff #66). Staff #66 stated that if a new resident was admitted , he will do an initial assessment which includes a skin assessment, a fall assessment, especially with a history of falls, ground level fall, wandering, dementia, old age, and new residents tend to be uneasy with a new place. He said that he will inform the certified nursing assistant (CNA) about the resident's risk of falls. He said that for resident identified as having a high risk for falls, the intervention includes lowering the bed, call light within reach, ask the provider to order floor mattress, place a yellow star for fall risk signage. He stated that for an unwitnessed fall, he will assess the resident, check their vital signs, notify the provider, director of nursing, start neuro check assessment. He said that neuro assessment was needed to compare resident's baseline and current situation and be aware of any changes or any injury. Regarding Resident #191, Staff #66 stated that he does not remember caring for the resident. Staff #66 stated that the unit manager initiates the baseline care plan; and he did not find a baseline care plan for resident #191 in the electronic medical record.A follow-up interview was conducted on January 28, 2026, at 5:11 PM with the director of nursing (DON/Staff #25). The DON stated that a fall assessment includes identifying diagnoses, history of falls, use of medications, any behaviors that can cause a fall, the resident's mobility, and orientation. The DON stated that if the resident was assessed as having a high risk for falls, she said to monitor, observe, check the resident, and report the high risk for falls to the staff. In addition, the DON stated other interventions such as, if a room was available to place the resident near the nurses' station, lower the bed, make sure the mattress does not slide out, have grab bars, call light within reach, anticipate the resident's needs, answer the call light promptly, and offer food and toileting before the resident goes to bed. Regarding Resident #191, who had 3 fall incidents, the DON stated that the resident has a fall care plan that did not have the resident at high risk for falls as indicated in the resident's fall assessment; she said that after the resident's fall incidents, the care plan was not updated. The DON stated that a resident's care plan is an interdisciplinary team approach because a care plan needs feedback from different disciplines, such as from dietary, rehab, or social services.According to MDS Training Institute, dated June 27, 2024, The intent of the baseline care plan is to promote continuity of care and communication among nursing home staff, increase resident safety, safeguard against adverse events that are most likely to occur right after admission and to identify needs of supervision, behavioral interventions, and assistance with activities of daily living.Per the CMS (Centers for Medicare &Medicaid Services) regulation at S483.21(a)(1), The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-Be developed within 48 hours of resident's admission.Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-Initial goals based on admission orders.Physician orders.Dietary orders.Therapy services.Social services.PASARR (Preadmission Screening and Annual Resident Review) recommendation, if applicable.A review of facility policy titled Fall Prevention adopted on May 1, 2024, revealed that it is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents. Each resident will be evaluated upon admission, quarterly, and as needed by an RN/LPN to assess his/her individual level of risk. The Interdisciplinary Team will review the Fall Risk Assessment completed by the nursing department, and if appropriate, a fall prevention protocol will be initiated. The purpose of the policy was to identify residents at risk in a timely manner; to gather accurate, objective, and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs; to ensure consistency in the implementation of preventive measures to assist with the reduction of falls; and to evaluate outcomes. The policy procedure include a licensed nurse will complete a Fall Risk Assessment within 24 hours of admit to determine the resident's risk factors associated with the potential for falls; the Interdisciplinary Team will be responsible for reviewing the Fall Risk Assessments, if assessed to be a high risk and/or is appropriate they will initiate fall prevention interventions; and the Director of Nursing/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced a recent fall have all recommended interventions in place as well as current assessments and documentation reflecting notification of applicable disciplines, resident's physician and resident's family/responsible party.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to review and revised the care plan for one resident (#191) after each fall incident. The deficient practice could place the resident at risk for more falls.Findings Include:Resident #191 was readmitted to the facility on [DATE], with diagnoses that included rhabdomyolysis (is a rare muscle injury where your muscles break down), adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit.A review of the Clinical admission Evaluation progress note dated August 3, 2024, revealed that the resident's admission mode was wheelchair. The Resident was alert and oriented times 3; alert (some forgetfulness).A physician-admission history and physical progress note dated August 3, 2024, revealed per documentation that resident was in a medical center with a 2- day history of weakness and falls at home, unable to ambulate with associated dizziness.An admission Morse Fall Scale Evaluation dated August 3, 2024, revealed a score of 65.0, indicating that the resident was assessed for high risk for falling.A review of the comprehensive care plan dated August 5, 2024, revealed that the resident had an activities of daily living self-care performance deficit related to deconditioning; the resident was at risk for falls related to deconditioning and gait/balance problems. The interventions initiated on August 5, 2024 included to encourage the resident to participate to the fullest extent possible with each interaction; encourage the resident to use bell to call for assistance; anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; the resident needs prompt response to all requests for assistance; and ensure commonly used items (ice water, glasses if applicable, call light, phone, remote) are within reach of resident prior to leaving room.On August 6, 2024, a Daily Skilled Charting progress note revealed per documentation, gait during shift-unsteady, poor balance during shift, bedfast all or most of the time during shift; the resident is sometimes displaying untoward behaviors, she refused to follow instructions, she insisted on doing her own. She insisted on going to the bathroom even if she has briefs on.Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score 6.0, indicating that the resident's cognition was severely impaired.On August 9, 2024, a nurses' progress note revealed per documentation, the resident was seen sitting on the floor with their back leaning on the side of the bed and both legs extended. The Resident claimed that she slipped slowly while trying to stand up to go to the bathroom. The resident was assessed, no noted bruises or skin tear; the resident was assisted back to bed; kept bed on lowest level for safety; neuro check was started; provider, assistant director of nursing, emergency contact were notified; put back non-slipped socks; reinstructed to use call light for assistance; and fall prevention signage was placed on the resident's room.Review of the Neurological Flow Sheet revealed a neuro check was completed on August 8, 2024, through August 13, 2024. The results of the neuro checks revealed that Resident #191 was fully conscious, her pupils' reaction was brisk, her speech was clear, she moved all of her 4 extremities equally and strong, and the Resident's vital signs were also monitored.Review of the comprehensive care plan dated August 5, 2024, related to activities of daily living, self-care performance deficit related to deconditioning, and the resident at risk for falls related to deconditioning and gait/balance problems revealed that the care plan was not updated after Resident #191 fall incident on August 8, 2024.On August 13, 2024, a nurses' progress note revealed per documentation, the resident was found lying on the floor; resident verbalized she did not hit her head; vital signs taken; neuro check started; no verbalized pain; resident was advised to use walker when ambulating; walker was placed at reach for use; bed was placed at the lowest position for safety; the provider and the assistant director of nursing (ADON) were notified; and the resident's emergency contact cannot be reached.Review of the Neurological Flow Sheet revealed a neuro check was completed on August 13, 2024 through August 16, 2024. The result of the neuro checks revealed that Resident #191 was fully conscious, her pupils' reaction was brisk, her speech was clear, she moved all of her 4 extremities equally and strong, and the Resident's vital signs were also monitored.Review of the comprehensive care plan dated August 5, 2024, related to activities of daily living, self-care performance deficit related to deconditioning, and resident at risk for falls related to deconditioning and gait/balance problems revealed the care plan was not updated after Resident #191 fall incident on August 13, 2024.On August 16, 2024, a nurses' progress note revealed per documentation, the incident was unwitnessed fall; resident was seen on the floor, on prone position; forehead laceration bleeding and was controlled; left knee skin tear; resident cannot verbalize what had happened prior to fall; she appears to be confused; resident was assessed; neuro check initiated; resident was able to verbalized pain over the affected area; 911 was called; resident was transferred out to the hospital; and management, provider, and emergency contact were notified.An interview was conducted on January 28, 2026 at 8:32 AM with a certified nursing assistant (CNA/Staff #148). Staff #148 stated that fall risk was discussed with the new admission. Staff #148 stated that for a fall risk resident, the mattress is placed at the side of the bed; she is instructed to lower the bed; and when the resident arrived from the hospital, the resident have a fall risk tag. Staff #148 stated that it was important to monitor the resident closely because the impact of residents not being monitored is that they can have a fracture, or be afraid to do things after a fall, lose confidence, and get hurt.An interview was conducted with a licensed practical nurse (LPN/Staff #85) on January 28, 2026 at 9:05 AM. Regarding fall, Staff #85 stated that staff can move resident closer to the nurses' station, have call light, increase safety checks; maybe have a fall mattress. Staff #85 stated that fall has a lot of risk such as broken bones, injuries and hospitalization.An interview was conducted on January 28, 2026, at 2:29 PM with the director of nursing (DON/Staff #25). The DON stated that staff perform fall assessment to monitor and anticipate the resident's needs; get to know the resident's routine and be one step ahead so staff can partner and the resident can be more compliant; and do not wait for the resident to ask. The DON stated that fall assessment and anticipating the needs and routine of the resident was important to prevent falls; altercations; prevent complaints and issues, illness, injuries, pain; the resident will be happier; and prevention is easier. The DON stated that the impact of a resident not being assessed for fall risk and their needs unmet could lead to falls, fractures, pain, or a decline in function.An interview was conducted on January 28, 2026, at 3:31 PM with a Registered Nurse (RN/Staff #66). Staff #66 stated that if a new resident was admitted , he will do an initial assessment which includes a skin assessment, a fall assessment, especially with a history of falls, ground level fall, wandering, dementia, old age, and new residents tend to be uneasy with a new place. He said that he will inform the certified nursing assistant (CNA) about the resident's risk of falls. He said that for resident identified as having a high risk for falls, the intervention includes lowering the bed, call light within reach, ask the provider to order floor mattress, place a yellow star for fall risk signage. He stated that for an unwitnessed fall, he will assess the resident, check their vital signs, notify the provider, director of nursing, start neuro check assessment. He said that neuro assessment was needed to compare resident's baseline and current situation and be aware of any changes or any injury. Regarding Resident #191, Staff #66 stated that he does not remember caring for the resident. Staff #66 stated that the unit manager initiates the baseline care plan; and he did not find a baseline care plan for resident #191 in the electronic medical record.A follow-up interview was conducted on January 28, 2026, at 5:11 PM with the director of nursing (DON/Staff #25). The DON stated that a fall assessment includes identifying diagnoses, history of falls, use of medications, any behaviors that can cause a fall, the resident's mobility, and orientation. The DON stated that if the resident was assessed as having a high risk for falls, she said to monitor, observe, check the resident, and report the high risk for falls to the staff. In addition, the DON stated other interventions such as, if a room was available to place the resident near the nurses' station, lower the bed, make sure the mattress does not slide out, have grab bars, call light within reach, anticipate the resident's needs, answer the call light promptly, and offer food and toileting before the resident goes to bed. Regarding Resident #191, who had 3 fall incidents, the DON stated that the resident has a fall care plan that did not have the resident at high risk for falls as indicated in the resident's fall assessment; she said that after the resident's fall incidents, the care plan was not updated. The DON stated that a resident's care plan is an interdisciplinary team approach because a care plan needs feedback from different disciplines, such as from dietary, rehab, or social services.A review of facility policy titled Fall Prevention adopted on May 1, 2024, revealed that it is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents. Each resident will be evaluated upon admission, quarterly, and as needed by an RN/LPN to assess his/her individual level of risk. The Interdisciplinary Team will review the Fall Risk Assessment completed by the nursing department, and if appropriate, a fall prevention protocol will be initiated. The purpose of the policy was to identify residents at risk in a timely manner; to gather accurate, objective, and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs; to ensure consistency in the implementation of preventive measures to assist with the reduction of falls; and to evaluate outcomes. The policy procedure include a licensed nurse will complete a Fall Risk Assessment within 24 hours of admit to determine the resident's risk factors associated with the potential for falls; the Interdisciplinary Team will be responsible for reviewing the Fall Risk Assessments, if assessed to be a high risk and/or is appropriate they will initiate fall prevention interventions; and the Director of Nursing/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced a recent fall have all recommended interventions in place as well as current assessments and documentation reflecting notification of applicable disciplines, resident's physician and resident's family/responsible party.

Based on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to identify elopement risks, and plan for effective supervision for resident one of three sampled residents (#888) related to risk factors for cognitively intact residents, and to ensure that one resident (#511) was supervised during activity sessions, and that activities were conducted safely. The deficient practice could result in avoidable accidents.Findings Include: -Regarding Resident #511 Resident #511 was readmitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus, factitious disorder imposed on self, borderline personality disorder, major depressive disorder, anxiety disorder, and Huntington's disease (is an inherited disorder, and develop uncontrollable dance-like movements (chorea) and abnormal body postures, as well as problems with behavior, emotion, thinking, and personality). The Resident's Clinical Resident Profile revealed that she was her own responsible party/representative. A review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating that the Resident was cognitively intact. The assessment also revealed that behavioral symptoms were not exhibited. The quarterly MDS assessment dated [DATE], revealed a BIMS score of 15.0, indicating that the Resident was cognitively intact. The assessment also revealed that physical and verbal behavioral symptoms occurred, and the Resident exhibited rejection of care and wandering behaviors. A review of care plan revised on January 15, 2025, revealed that the Resident demonstrates significant problems with leisure skill and time planning related to Borderline personality disorder manifested by cognitive and neurological impairment; and at risk for harm to self or others as evidence by pulling out her hair and throwing it to the ground, throwing food, tray covers, empty drink bottles at staff and will hit her hand on the arm of her chair. The goal was that the Resident would not harm themselves or others. The interventions included assisting the Resident to activity of choice; if her behaviors become disruptive in group activities, the Resident will be escorted back to her hall until she calms down, she may return to the group function to participate; care in pairs; have supervisory personnel observe care delivery, as possible, and in accordance with privacy and dignity considerations. An activity observation was conducted on January 26, 2026, at 1:59 PM, held in the first-floor dining room. Resident #511 was observed sitting in her wheelchair on one end of the table, slightly away from the tables where other residents were seated. Resident #511 was interacting with a staff member who was holding a cellphone displaying images of products from the cellphone to Resident #511. About 3 other residents were also seated on the other side of the table, opposite/facing Resident #511. Some residents who were seated in front of the tables were singing along with the music. Several other residents who were seated in front of a table were holding a green colored play gun with foam darts aiming at a couple of balloons placed in front of the tables and the residents. The residents were engaged with the activity being provided. Resident #511 was playing with the toy gun with foam darts while seated at one side of the table and pointing at the balloons. At one point during the activity, a foam dart landed on Resident #511. Resident #511 picked the foam dart and inserted into the play gun she was holding. At 2:33 PM, the only activity aide (Staff #192) during the activity wheeled a resident out of the dining/activity room. There were no other staff in the dining/activity room. At 2:34 PM, the activity aide (Staff #192) returned to the dining/activity room. An interview was conducted on January 26, 2026, at 2:56 PM with an activity aide (Staff #192). Staff #192 stated that his responsibilities included escorting and entertaining residents by providing activities to occupy their time, distributing mails and packages, and he handling residents' smoke breaks. He stated that the activity today was an exercise for eyesight, target practice, coordination, and karaoke/music therapy. Regarding the target practice coordination activity using a toy gun and foam darts, he stated that the potential for hitting someone would not cause an injury. He said that he had used this activity in the past, and the residents were good at not targeting each other because they were being supervised. He added that verbal arguments happened in the past, like whose turn it is, and they were de-escalated immediately. He also said that the residents who attended the activity were from the long-term care unit and the behavioral health unit. Regarding Resident #511, he said that Resident #511 was seated on one side; Resident #511 likes to sit with her own table, and there was no way to lower Resident #511's wheelchair so she could sit in front of the table alongside the larger group. He stated that Resident #511 seating location was accommodated based on the resident's choice. He also said that Resident #511 was from the behavioral unit, and Resident #511 would be confrontational. Further, he stated that the residents from the behavioral unit are 100 percent supervised during activities. He stated that today, his coworkers were busy, so he stepped out and escorted out one resident. The activity director (Staff #15) was interviewed on January 28, 2026, at 9:12 AM. The activity director stated that during activity sessions, they can have residents from the behavioral unit, memory care unit, and the open unit. She said that she has activity games with prizes; this week the activity involved using a play gun and foam darts; and the game was about target practice by hitting the balloons. She said that the balloons were placed opposite of the tables; the residents should be 2 to 3 feet apart from facing the balloons, and the residents should be lined up across/in front of the balloons so no one could get hurt by preventing a resident from getting hit with the dart. She also said that if a resident was seated on one side and another resident was seated on the other side, the resident could be hit with the dart, and can trigger a behavior. She said that the activity aide should have moved the residents to where they should have been placed in one line in front of the balloons. Further, she stated that the residents who attended the Monday activity were all from the behavioral long-term unit; one staff per activity; the staff has to be there all the time as long as there are residents in the activity room; the staff can't leave the room; if the staff needed assistant, the staff should have called her or a certified nursing assistant (CNA). The activity director stated that if there was no staff with the residents during an activity session, the residents could have behaviors, the residents could wonder in the kitchen, or go out to the hall, and it was not safe for the residents. The activity director stated that the staff were supposed to call using their facility system connect or use their own personal phone or message her if needing to bring a resident back. -Regarding Resident #888: Review of Resident #888's hospital records prior to admission revealed that he was admitted to the hospital on [DATE], with diagnoses that included abscess of the left thumb, left arm cellulitis, drug use, amphetamine use, moderate fentanyl dependence, and suicidal ideation. Discharge medications included daptomycin 400 mg in 0.9% normal saline, 20 mL IV. The records documented that the resident reported feeling improved and inquired about obtaining medical marijuana upon hospital discharge. Resident #888 was admitted to the facility on [DATE], with diagnoses that included cellulitis of the left upper limb, cellulitis of the left finger, bronchitis, iron deficiency anemia secondary to blood loss, stimulant abuse, in remission, opioid dependence, suicidal ideations, unspecified lack of coordination, and need for assistance with personal care. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed that Resident #888 had a BIMS score of 14, indicating that the resident was cognitively intact. Review of a psychosocial evaluation dated January 9, 2026, revealed that Resident #888 reported diagnoses of bipolar disorder and schizophrenia. The evaluation further revealed that the resident had served approximately 20 years in prison and was currently on parole. Review of a smoking evaluation for resident #888 dated January 9, 2026, revealed that Resident #888 was a smoker and preferred to smoke in the mornings and afternoons. Further, the evaluation revealed that Resident #888 had no limitations regarding his ability to smoke independently and could light his own cigarettes. Resident #888 was considered a safe smoker and could access smoking materials consistent with the facility's policy with frequent monitoring. Review of a wandering/elopement risk assessment dated [DATE], revealed that Resident #888 had a score of 5.0, indicating low risk for wandering or elopement. The assessment evaluated mobility, mental status, speech, and history of wandering; however, it did not address psychosocial, behavioral health, or substance-use-related risk factors. A nursing progress note dated January 9, 2026, revealed that at 6:45 p.m., Resident #888 requested to shower. His right arm peripherally inserted central catheter (PICC) line and left arm wound dressing were covered, and he showered independently. At 7:10 p.m., staff informed the resident that the PICC line and wound dressing required changing. The resident requested that the dressing change occur after the 7:30 p.m. smoking break. At approximately 7:40 p.m., the on-duty receptionist (Staff #35) reported observing Resident #888 get into a black car and leave the facility following the smoking break. The provider was notified, and 911 was called. On January 10, 2026, an Against Medical Discharge (AMA) release form was entered into the clinical record for resident #888. The document revealed that on January 9, 2026, at 7:40 p.m. during smoking break, Resident #888 got in a black car and left the facility. The physician and administrator were notified, and 911 was called. Attempts to contact Resident #888 by telephone were made on January 26, 2026, at 8:40 a.m. and 12:21 p.m., and January 27, 2026, at 11:56 a.m. No answer was received, and staff were unable to leave voicemail messages. Attempts to contact Staff #35 by phone were made on January 27, 2026, at 12:41 p.m., 3:45 p.m., and 4:51 p.m. Voicemail messages were left each time, and no return calls were received. On January 27, 2026, at 12:29 p.m., an interview was conducted with a receptionist (Staff #9). Staff #9 stated that staff receive training on how to respond to elopement events and how to communicate with staff and law enforcement. Staff #9 further stated that residents are monitored during smoking breaks and that posted smoking times were 6:30 a.m., 9:30 a.m., 12:30 p.m., 4:00 p.m., 7:30 p.m., and 10:00 p.m. daily. On January 27, 2026, at 12:57 p.m., an interview was conducted with the case manager (staff #6). Staff #6 stated that newly admitted residents are assessed for cognition, psychosocial needs, and wandering/elopement. Staff #6 stated that the wander assessment focuses on cognition and assesses residents for both wandering and elopement. The hospital records reveal diagnoses and conditions that could indicate higher risks for elopement than the wandering/elopement screening at the facility. Upon review of the hospital discharge documentation for resident #888, Staff #6 stated that suicidal ideation, homelessness, and drug use could indicate a higher risk of elopement, and a resident with these concerns should be referred to behavioral health. On January 27, 2026, at 1:59 p.m., an interview was conducted with the Director of Nursing (DON, Staff #25). Staff #25 stated that hospital records are reviewed upon admission and that narcotic use, homelessness, and suicidal ideation are risk factors for elopement. After reviewing the wandering/elopement assessment for Resident #888, Staff #25 stated that the assessment did not adequately evaluate the resident's risks and did not capture his needs and concerns. Staff #25 further stated that the wandering/elopement assessment for Resident #888 did not provide sufficient information to accurately evaluate his elopement risk. Staff #25 stated that potential risks for the resident included self-harm, suicide, illegal drug use, and infection related to the PICC line and open wound, and that newly admitted residents should be closely monitored. Staff #25 stated that Resident #888's life was at risk. Staff #25 stated that leaving against medical advice (AMA) differs from elopement, as AMA requires that the resident be informed of the risks and sign documentation prior to leaving. Staff #25 stated that Resident #888's departure should have been considered an elopement, not an AMA discharge. On January 27, 2026, at 4:54 p.m., an interview was conducted with the on-duty receptionist (Staff #45). Staff #45 stated that staff rotate responsibility for monitoring residents in the smoking area and that the receptionist is responsible for monitoring residents during the 6:30 a.m. and 7:30 p.m. daily smoking times. On January 27, 2026, at 5:03 p.m., a telephone interview was conducted with the resident's only listed emergency contact. The family member stated that she lived out of state and was unable to be present to monitor the resident's care or behaviors. She stated she was informed that Resident #888 eloped from the facility on January 9, 2026, but was not informed of why he left or who transported him. The family member stated that the resident's whereabouts were unknown until he was located by police and was currently incarcerated. On January 28, 2026, at 6:55 a.m., observation revealed three residents smoking outside the facility without staff supervision. The receptionist on duty was observed seated inside the building at the reception desk. Review of the facility policy titled Policy/Procedure – Nursing Administration, Subject: Elopement, adopted May 1, 2024, revealed that the facility policy required all residents to receive adequate supervision to ensure the safest environment possible and required that residents be assessed for behaviors or conditions that place them at risk for wandering or elopement. Review of facility policy titled Activity/Recreation Therapy Program revised in August 2023, revealed that activities/recreation therapy programs are provided in coordination with the resident's comprehensive assessment.

Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and policy review, the facility failed to protect the resident's (#10) rights to be free from abuse by another resident (#5). This deficient practice could result in further incidents of resident to resident abuse. Findings include:-Resident #5 (Alleged Perpetrator) was admitted to the facility on [DATE], with diagnosis that include depression, psychosis, anxiety, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated November October 6, 2025 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognitive function. A review of Resident #5's care-plan revealed the resident had a confirmed resident to resident altercation, and a history of such, as well as a history of resident to staff altercations, with noted goals including, resident will have no altercations with staff or residents through the review date, and noted interventions of remove resident from the environment when escalation verbally begins to occur. A review of progress notes dated December 14, 2025 at 7:42 p.m. revealed at approximately 1630, a Certified Nursing Assistant (CNA) informed that Resident #5 and Resident #10 were in the hallway was yelling do you want to fight?, went towards Resident #5, attacked, scratched her left arm, and Resident #10 backed up. Resident #10 stated while I was in my wheelchair she just stood and stared me down. The nurse and CNA immediately separated the residents, and Resident #5 was redirected to her room. The note concluded that Resident #5 was educated on proper behavior, and that the provider, unit manager, DON, administrator, and POA were all notified. A review of skin assessments for Resident #5 dated December 15,2025 at 3:14 a.m., revealed the cause for the skin assessment was she scratched me, and noted that Resident #5 had suffered three, 3mm(millimeter) by 3mm skin tears, However, the note was struck out with no reason given, and concluded that the nurse had contacted the POA for Resident #5, with a message left.A review of social service progress notes for dated December 15, 2025 at 10:08 a.m., revealed that social services reviewed and documented the incident involving Resident #10 and Resident #5 that occurred at approximately 1630 hours. Per staff report, Resident #5 approached Resident #10 in the hallway in an agitated manner, verbally stating, Do you want to fight? Resident #5 advanced toward Resident #10 and scratched Resident #10 on the left arm. Resident #10 backed away and verbally stated, I didn't do anything. I was just standing there and she scratched me. Staff intervened immediately, and residents were separated. Resident #10 was promptly assessed for injury. Assessment revealed three superficial skin tears measuring approximately 3 mm x 3 mm each on the left arm, with a small amount of bleeding noted. Wound care was performed per facility protocol. The provider was notified of the incident and injury, orders were received, and wound care was continued per order. Resident #10 reported pain at the site of injury and was administered PRN Tylenol with good tolerance. No further distress was observed. The Unit Manager, Director of Nursing, and Administrator were notified. The resident's POA was contacted, and a voicemail was left requesting a return call.A different skin assessment for Resident #5 dated December 15, 2025 at 1:49 p.m., revealed the cause was another resident scratched her and that the resident had an injury on upper left antecubital, however, the measurements on the previous skin assessment that was struck out were not included.-Resident #10 (Alleged Victim) was admitted to the facility on [DATE], with diagnoses that include dementia, hypertension, chronic kidney disease, and depression.An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 which indicated the resident had significant cognitive impairment. An interview was conducted with a resident representative (RR/#60) for Resident #10 on January 5, 2026 at 12:26 p.m. The RR stated that she spoke to someone at the facility about the incident, but that the details weren't clear because the person who called her didn't speak English well. The RR stated that she was caught off guard and that she was told by the facility that Resident #5 can be a little intrusive. The RR concluded that she was told about the incident, and that resident #10 had a skin tear on her arm as a result, but that was it.An interview was conducted with a resident representative (RR/#70) for Resident #5 on January 5, 2026 at 12:36 p.m. The RR stated that he was told Resident #10 had some wandering behaviors. He stated that what he thinks happened was Resident #10 kept poking her head into Resident #5's room and Resident #5 reacted to it, and had enough of it I guess. The RR stated that Resident #10 grabbed Resident #5 and scratched her, and stated that Resident #10 gets cabin fever and has otherwise been doing very well. He concluded that you can't really predict who is going to have a bad day.An interview was attempted with Resident #5 on January 5, 2026 at 1:35 p.m., however the resident was unavailable for interview.An interview was attempted with Resident #10 on January 5, 2026 at 1:50 p.m. Resident #10 was noted to be pleasantly confused and stated that she didn't see anything when asked about the incident, and stated Did they say if it was a man or a woman? I don't know. An interview with a Licensed Practical Nurse (LPN/#150) was conducted on January 5, 2026 at 2:02 p.m. The LPN stated Resident #10 is pleasantly confused, and alert and oriented 1-2 out of 4 most of the time. He stated that she is compliant with care, and pleasant most of the time, but that she can be a little anxious and restless. He also stated Resident #10 wanders a lot. The LPN stated he had heard about the incident but did not witness it. The LPN stated that there are lots of different kinds of abuse, financial, sexual, physical, and emotional, anything that takes advantage of the resident. The LPN further that the incident would be abuse and would consider the blame to fall on the employees for not preventing it. The LPN concluded that the administrator is the abuse coordinator and that's who they would report abuse to.An interview was conducted with the Director of Nursing (DON-RN/staff #90) and the Administrator (Admin/staff #100) was conducted on January 5, 2026 at 2:40 p.m. The DON stated that during the incident Resident #5 and Resident #10 were in the hallway, and Resident #5 had stated Do you wanna fight? to Resident #10 which caused the incident. The DON further stated the residents were separated immediately following the incident and that Resident #10 had sustained a scratch on her left arm. The administrator stated that the scratches were not deep, very superficial, and acknowledged that their internal investigation substantiated the complaint. The DON concluded that yes, she would call the incident physical abuse, and that it has to be treated like residents with behaviors, and that it does not meet her expectations. The administrator concluded that it was reported, and that they substantiated it stating further If it happened it happened, it doesn't matter if it was intentional or not.A facility policy titled 'Resident rights - Abuse and Neglect adopted May 1, 2024, revealed it is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. This includes but is not limited to freedom from any physical or chemical restraint not required to treat the resident's medical symptoms.

Based on clinical record review, interviews, review of facility documentation and policies, the facility failed to protect The rights of one resident (# 07) to be free from verbal and physical abuse by another resident (#33). This deficient practice has the potential to violate the resident's right to safety and prevent further harm. The sample size was 5. The facility census was 122. Findings include: -Regarding resident #7 Resident # 7 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified mood (affective) disorder, and autistic disorder. A review of the Interdisciplinary Team (IDT) Care Conference dated June 24, 2025, revealed the resident had a Brief Interview Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. A review of the shower sheet dated December 2, 2025 revealed no issues were identified on the skin.A review of the nurse progress note dated December 3, 2025, revealed that the resident requested to have a room change, and was transferred to a different room on December 3, 2025. A review of the nurse progress note dated December 6, 2025, revealed that the resident complained that roommate Resident #33 had turned off the TV. Staff noted that Resident #33 stated the room was his, but nursing clarified that the room was shared by both residents.A review of the nurse progress note dated December 7, 2025, revealed that at 7:15 a.m., the Registered Nurse (Staff #25) heard a CNA yelling, Stop that, and immediately investigated. The progress note revealed that Staff #25 witnessed the CNA (Staff #88) separate and redirect Resident #33, who was attempting to hit resident #7 on the left arm while the resident was lying in bed. The note indicated that an assessment was performed and the skin was found intact, and that resident #7 denied pain. The note included that resident #7 was moved to another room on the unit and the family was notified.A psych follow-up progress note dated December 8, 2025, revealed the resident was seen for a routine psychiatric follow-up. The note revealed that staff reported to the provider that the resident had a recent altercation with his roommate, and that the resident did not recall the incident and was redirected to a different room. A social service note dated December 8, 2025, revealed the Social Services Director (SSD/Staff # 28) met with the resident, who was unable to recall any details about the incident that occurred over the weekend. Staff # 28 described Resident # 7 as having an overall stable, calm, and appropriately engaged presentation, with no observed behavioral concerns during the assessment. A day after the alleged incident, a weekly skin observation dated December 8, 2025, noted discoloration on the resident's right upper extremity and redness on the right side of the face. Additional notes indicated the facial redness was attributed to the resident sleeping on that side.A shower sheet dated December 9, 2025 revealed the resident had a fungus under the stomach. A weekly skin observation, dated December 9, 2025, revealed the resident had redness under the abdominal folds of both iliac crests. A review of the victim of physical abuse by roommate care plan, initiated on December 9, 2025, revealed the resident was referred to social services and behavioral health for emotional support, and that the resident was moved to another room for safety and emotional wellbeing. Regarding Resident # 33Resident # 33 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, anxiety disorder, unspecified, major depressive disorder, recurrent, unspecified, and unspecified psychosis not due to a substance or known physiological condition. A psychosocial evaluation, dated April 17, 2025, revealed the resident had a BIMS score of 3, which indicated severe cognitive impairment. The evaluation also revealed the resident had no impaired or slurred speech, with normal vision and hearing. A resident's behavior care plan, revised on September 5, 2025, indicated the resident had exhibited behavioral outbursts, including crying and overstimulation, with occasional refusal to change environments. Interventions included the provision of a structured, calm, and consistent environment to promote safety and minimize triggers associated with cognitive decline and behavioral disturbances.A psych follow-up progress note dated December 2, 2025. revealed that staff reported to the provider that the resident became aggressive at times with another male resident but was easily redirected. An IDT progress note dated December 4, 2025, revealed that resident #33 demonstrated behaviors that included, but not limited to: pacing the hallways, verbal and physical aggression, and noncompliance with cares and treatments. A nursing progress note dated December 6, 2025, revealed that staff needed to diffuse a situation which involved resident #33 unplugging resident #7's television. A nursing progress note, dated December 7, 2025, revealed the resident #33 had to be redirected from hitting Resident # 7, and was provided reorientation/education on proper behavior. A review of the psych follow-up progress note, dated December 8, 2025, revealed the provider deemed the current risk to patient safety to be low, and that a safety plan was not required for resident #33.A review of the social service progress note dated December 8, 2025, revealed resident #33 was interviewed by the social services director, and described the altercation as stemming from the other resident (Resident #7), becoming upset about the lights being turned off. The note revealed the director attempted to explore the resident's own behavior that may have contributed to the event, but rather remarked I guess he is gone now. A psychiatry/mental health progress note dated December 10, 2025, revealed resident #33 had a history of combative behavior, abusive, and threatening verbal/physical outbursts. The note revealed the provider was informed that the resident was reported to have struck his roommate in the arm, which required staff to separate the parties involved in the altercation. A Facility Reported Incident (FRI) follow up report, submitted December 10, 2025, revealed that the facility concluded that the allegation of resident to resident abuse was verified regarding the incident between resident #7 and resident #33 An interview was conducted on December 10, 2025, at 10:50 with Resident #33. The resident reported that staff were notified over the past two days that the new roommate (resident #7) talked excessively at night, played the television too loudly, and needed to lose weight. Resident #33 stated that the roommate was instructed to turn off the television and that frustration occurred when the roommate did not immediately comply. Resident #33 reported warning staff to intervene before matters were taken into Resident #33's own hands. Resident #33 stated that, due to lack of staff intervention, had to beat the roommate's dumb fat ass! (referring to resident #7). Resident #33 stated that he told staff that he took responsibility for his actions, but also expressed that the actions were justified, due to how resident #7's behavior kept pissing off resident#33. Toward the conclusion of the interview, resident #33 retracted the statement and denied directing any physical violence towards resident #7, and stated that violence would only occur if the resident was struck first. Resident #33 stated, If the roommate laid a hand on me, I would kick the dumb ass Resident #33 further stated, But no I did not hit him, I was in bed the whole time, and added, I didn't do anything to that fat bastard. Resident #33 further stated a lack of awareness regarding staff concerns and stated that resident #7 better not accuse me of anything. Resident #33 expressed feeling safe at the facility and was not aware of any residents that were being intimidated or abused by any staff or other residents. An interview with Resident #7 was attempted on December 10, 2025, at 11:00 a.m.; however, the resident was unable to be interviewed. Additionally a second interview was attempted with staff assistance however, the resident was not able to participate in an interview.An interview was conducted on December 10, 2025, at 11:06 a.m. with the Behavioral Health Therapist (BHT/Staff #15). Staff #15 stated that Resident #33 did not get along well with roommates and suspected the behavior was intentional due to improved behavior when Resident #33 had a private room. Staff #15 stated that Resident #33 had multiple triggers, including loud television volume and arguments. Staff #15 stated being informed of the incident between Resident #33 and Resident #7 through report and indicated the incident involved Resident #7 turning off a light. Staff #15 stated that Resident #33 was observed arguing with another resident earlier that morning. Staff #15 stated that the most effective approach when working with Resident #33 was the use of a calm, controlled, and firm tone with frequent redirection. Staff #15 stated that Resident #7 did not exhibit aggressive behaviors and had a diagnosis of dementia with associated confusion. Staff #15 stated being recently returned to the unit and being informed that nursing staff relocated Resident #7. Staff #15 stated that the placement would not have been recommended due to Resident #7 frequently receiving visitors and having prior roommate-related issues. Staff # 15, revealed that staff in the behavioral unit were undergoing additional training, to better handle situations and challenges unique to the lockdown unit. An interview was conducted on December 10, 2025, at 2:19 p.m. with Certified Nurse Assistant (CNA/Staff #88). Staff #88 stated that while passing the room, loud verbalizations were heard from Resident #33, described as louder than baseline and inconsistent with Resident # 33 usual calm and playful behavior. Staff #88 stated hearing inappropriate language from Resident #33, including, Why don't you leave the light alone you son of a bit--! Staff #88 stated that work duties were stopped and observation revealed Resident #33 punching Resident #7 once on the side. Staff #88 stated immediate intervention occurred, when the staff member separated Resident # 33 from Resident #7. Staff #88 stated the nurse in charge responded and assisted with de-escalation. Staff #88 stated that Resident #7 was lying on the right side of the bed at the time of the incident and did not respond to Resident #33. Staff #88 described Resident #7 as calm and nonreactive throughout the event. Staff #88 stated that Resident #7 appeared unharmed following the incident. Staff #88 stated that nursing staff assessed Resident #7 and redirected Resident #33 away from the area. Staff #88 stated the incident occurred during early morning hours. Staff #88 revealed a lack of awareness regarding the resident's behavior care plan. Staff #88 stated that Resident #7 had been moved into the shared room approximately three to four days prior to the incident. Staff #88 could not recall any conflict between the current two roommates, but stated they were only together for about a week. Staff #88 described Resident #7 as pretty calm, and Resident #33, being upset over a light in the room.An interview was conducted on December 10, 2025, at 2:41 p.m. with Registered Nurse (RN/Staff #21). Staff #21 stated that both residents were roommates and were asleep at the start of the shift at 6:15 a.m. Staff #21 stated concern regarding the roommate pairing due to Resident #33's history of agitation, possibly dementia-related aggressive behaviors. Staff #21 voiced surprise that Resident # 7 was paired with Resident # 33, after learning that Resident # 7 previous roommate exhibited inappropriate sexual behaviors, i.e. masturbation, around Resident # 7 visitors. Staff #21 stated that while performing rounds, Staff #88 entered to take vital signs and was heard yelling Stop it! Stop it! Staff #21 recalled running to the room and observed Staff #88 placed in-between the two roommates. Staff #21 stated being the second staff member to enter the room. Staff #21 stated that Resident #7 remained in bed during the altercation. Staff #21 stated that Resident #33 appeared to continue to show aggressive behaviors and was escorted from the room. Staff # 21 recalled that report was received from Staff #88 who witnessed Resident #33 punch Resident #7 on the left side. Staff #21 stated that Staff #88 removed Resident #33 from the room. Staff #21 stated that vital signs were obtained and were within normal limits. Staff # 21 also performed skin and pain assessments which revealed no abnormalities. Staff #21 stated that upper management was contacted to report the incident and that Resident #7 was relocated to a more appropriate roommate assignment. Staff #21 stated that the last few days with the new roommate assignment had progressed well. Staff #21 stated that Resident #7 was placed on 15-minute monitoring checks and that all shifts were informed to continue routine skin assessments. Staff #21 stated that a behavioral health consult was submitted for Resident #33 due to increased agitation and mild sundowning behaviors.An interview was conducted on December 11, 2025, at 8:34 a.m. with the resident's insurance Registered Nurse Manager (Staff # 125). Staff #125 stated that the case manager (Staff # 222) was not available at the moment, but verbalized unawareness of the incident and voiced significant concern regarding resident safety and the roommate selection. Staff #125 stated that management would be immediately contacted to follow up on concerns related to resident safety.An interview was conducted on December 11, 2025, at 9:44 a.m. with the Social Services Director (SSD, Staff #28). Staff #28 stated that room compatibility was assessed using multiple factors, including cognition, mood, coordination, case management considerations, grievances, and overall room safety. Staff #28 also stated that care planning included meetings with families, long- and short-term care providers, and insurance representatives, with a focus on resident advocacy and safety. Staff #28 stated that the rationale for assigning Resident #7 as a roommate to Resident #33 included that the prior roommate, quietly engaged in frequent episodes of masturbation, while Resident # 7 had visitors. Staff # 28 verified the former roommate was care planned for one on one staff cares due to sexual harassment of the staff. In regards to the resident presence in room while the former roommate masturbated, Staff # 28 stated that staff-maintained privacy by drawing the curtain in accordance with residents' rights to sexual expression. Staff #28 stated that Resident #7 had a diagnosis of autism and could become overstimulated without a specific trigger in certain environments; however, Staff #28 stated Resident #7 was rarely in the room, and the roommate masturbated quietly, which reduced perceived risk of exposure to Resident #7. Staff #28 verbalized that nursing staff made the decision to reassign Resident # 7 to Resident #33's room. Staff #28 stated awareness of Resident #33's behaviors and stated that both residents were deemed appropriate for shared room placement, and the room assignment was maintained.An interview continued on December 11, 2025, at approximately 9:50 a.m. with the Interim Director of Nursing (IDON, Staff #100), the Director of Nursing Trainee (Staff #61), and the Social Services Director (Staff #28). Staff #100 stated that room moves were determined on a case-by-case basis. Staff # 100 revealed individualized care planning is implemented when a resident becomes agitated or when a move was necessary for roommate safety. Staff #100 stated that roommate assignments remained fluid to accommodate resident need. Staff #100 stated that roommate compatibility was also influenced by environmental factors, including television use and noise levels. Staff #100 stated that facility expectations required assessment of each resident's behaviors to determine roommate compatibility. Staff #100 stated that behavior charting and progress notes were expected to document behaviors and interventions. Staff #100 stated that resident safety was the highest priority and that abuse was not permitted, with all efforts directed toward prevention. Staff #100 revealed that although additional staff training was required and that nurses retained autonomy to make safety-based decisions when necessary.An interview was conducted on December 12, 2025, at 10:06 a.m., with the resident's insurance case manager (Staff # 222) who stated that the resident is now safe and the family is considering different options for resident care needs available for the resident. A review of the Resident Rights/Abuse Neglect policy, adopted May 1, 2024, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure residents (#1, #3, and #5) were free from abuse and neglect. The deficient practice could lead to physical and psychosocial harm to the residents. Findings include: -Regarding Resident #1 and #2 -Resident #1 was admitted to the facility on [DATE] with diagnosis that included spinal stenosis, Dementia, and major depressive disorder. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #1 completed a Brief Interview for Mental Status (BIMS) score of 09 indicating moderate cognitive mpairment. -Resident #2 was admitted to the facility on [DATE] with diagnosis that included rib fractures, anxiety disorder, low vision in the Right eye, psychosis and Dementia. A review of the admission MDS, dated [DATE], indicated Resident #2 had a BIMS score of 02 indicated severe cognitive impairment. The same MDS also noted that Resident #2 was also inattentive, experienced disorganized thinking, physical and verbal behaviors, rejection of care, and wandering. A care plan initiated on March 29, 2025, revealed resident #2 experienced escalated physical and verbal aggression and was residing in a secured unit. Interventions included 1:1 supervision due to resident safety. A nurses' note, dated April 14, 2025 at 10:44 AM indicated that on April 11, 2025 resident #2 was taken off of 1:1 staffing on a trial basis due to a reduction in his behaviors. The nurses' note indicated that on April 13, 2025 resident #2 had a, violent outburst-difficult to redirect and that he was physically aggressive with a peer and a staff. The note revealed that resident #2 attempted to stand on a night stand and go out through a window. An order for resident #2 to be sent to the hospital to determine if there was an underlying medical condition was requested. A second nurses' note, dated April 14, 2025 at 11:47 AM indicated that the Physician authorized resident #2 to be sent to the hospital. An interview was conducted on April 22, 2025 at 8:59 AM with Certified Nursing Assistant (CNA/Staff #112) who that resident #2's typically can come off as aggressive when staff attempt to redirect him as he does not like being told what to do. Staff #112 defined aggressive as physical hitting or slapping staff. Staff #112 confirmed that she witnessed the altercation between Resident #1 and #2. Staff #112 stated that Resident #2 had come out of his room and was attempting to go into Resident #1's room. Staff #112 attempted to redirect resident #2 but was unsuccessful and he was able to enter Resident #1's room. When staff #112 attempted to redirect Resident #2 out of Resident #1's room, he elbowed staff #112 on the side of the head. As Staff #112 attempted to assist Resident #1 out of her room, Resident #2 hit her on top of her right breast. Staff #112 called for assistance and two nurses came to redirect Resident #2. Staff #112 stated that the risk to the residents if they were abuse by other residents was having a more serious injury. An interview was conducted Licensed Practical Nurse (LPN/Staff #78) on April 22, 2025 at 9:16 AM who described Resident #2 as being confused and sometimes would try to go into other residents' rooms. Staff #78 stated that she was working the shift after Resident #2's altercation with Resident #1. Staff #78 also added that when the police had come to speak with Resident #1 about the incident, the resident had remembered a little bit but not much. She had just remembered that a resident had gone into her room and beat her up. When asked what the risks are to residents who are abuse by other residents, Staff #78 stated that residents could have injuries as well as emotional trauma. An interview was conducted with the Assistant Director of Nursing (ADON/Staff #63) on April 22, 2025 at 12:56 PM. Staff #63 described Resident #1 as someone who did not wander and was aware of what she's doing at the moment. Resident #1 was also described as someone who liked to socialize and do art projects. Staff #63 explained that Resident #2 was confused all the time, would wander around the unit, and move things in his room. She stated that staff would often attempt to redirect him to where he needed to go but he was resistive to the redirection. She also indicated that he was hard to redirect as well. Staff #63 stated that Resident #2 had gone into Resident #1's room and Resident #2 had hit Resident #1 on her chest near her pacemaker and the CNA had immediately attempted to separate the two residents. There were no injuries noted by the nurse and the wound nurse after the incident. When asked what were some possible risks to the residents when they are abused by other residents, Staff #63 indicated that the abused could have physical harm, emotional damage and the resident could also not feel safe. -Regarding Resident #3 and #4 -Resident #3 was admitted to the facility on [DATE] with diagnoses that included bipolar, insomnia, borderline personality disorder, and type 2 diabetes. A review of the admission MDS, dated [DATE], indicated Resident #3 had a BIMS assessment completed and scored a 13 which indicated she was cognitively intact. Review of the progress notes for Resident #3 revealed a Nurses Note, dated April 13, 2025 at 7:30 PM, indicating Resident #3, received physical aggression from resident in 106B. The note indicated there were no injuries or pain reported. An interview was conducted on April 21, 2025 at 1:45 PM with Resident #3 in her room. Resident #3 explained that another resident, who was moved to a different unit, had gone into her room, was laying on her bed and was wrapped in her blanket. Resident #3 then was able to get the other resident (Resident #4) out of her bed. As Resident #4 was walking to the door, Resident #3 asked for her blanket back as she grabbed it Resident #4 had hit Resident #3 in the back of the head hard with a closed fist. -Resident #4 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder, Alzheimer's disease, and dysphagia. A discharge MDS, dated [DATE], indicated that a staff assessment for cognitive skills for daily decision making was severely impaired. The same MDS assessment indicated that Resident #4 wandered every 1 - 3 days. A care plan, revised on March 5, 2025, included a focus area of Resident #4's physical aggression towards others, wandering and exit seeking due to her Alzheimer's dementia diagnosis. Interventions included frequent checks for safety, documenting behaviors, and notifying the psych provider as needed. A review of progress notes revealed a nurses' note, dated April 13, 2024, that a resident had found Resident #4 in her bed. As the CNA assisted Resident #4 out of the room, she had become physically aggressive and placed on 15-minute checks. An interview was conducted on April 22, 2025 at 11:38 AM with CNA/Staff #175 who stated that the incident had occurred at the start of her shift when Resident #3 called out for her and told her that another resident was in her bed. Staff #175 indicated that she had observed Resident #4 sitting on Resident #3's bed and had Resident #3's wallet and blanket with her. Staff #175 indicated that Resident #4 is typically cooperative and redirectable when you finesse it with her by saying something like let's go check out something in the hallway. Resident #4 was more combative saying, this is my bed, this is my stuff. As I was attempting to have Resident #4 give Resident #3 her blanket and wallet back, I was telling Resident #4 that I would give her another blanket. Resident #4 then turned around and hit Resident #3 on the shoulder three times. Staff #175 shared that she then stepped in between the two residents and assisted Resident #4 out of the room. A telephonic interview was attempted on April 22, 2025 at 2:49 PM with Staff #142, however, she declined to participate in this investigation. An interview was conducted on April 22, 2025 at 12:56 PM with Staff #63 who stated that Resident #4 was a wanderer and would walk into other residents' rooms. She also stated that Resident #4 was mostly redirectable but sometimes can be difficult. Staff #63 stated that she did not know what triggered the incident between Residents #3 and #4 but she knew that Resident #4 had either hit or slapped Resident #3 on the forehead. Regarding Resident #5: Resident #5 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, schizophrenia, and anxiety disorder. A review of the quarterly MDS assessment, dated January 25, 2025 revealed Resident #5 completed a BIMS and scored a 06 which indicated she had moderate cognitive impairment. A review of the care plan, revised on April 10, 2025, includes a goal of Resident #5 ensuring she was safe from burns using a non-spill cup when drinking warm/hot beverages, however, there were no interventions listed for this goal. A review of Resident #5's progress notes in the Electronic Health Record (EHR) note, dated April 10, 2025 at 1:25 PM, revealed that Resident #5 had sustained a burn on her right thigh from, very hot coffee while at activities on (April 9, 2025). It also indicated the resident's Power of Attorney (POA) and the provider were notified of the injury. A review of the Weekly Skin Observation assessment, dated April 10, 2025 at 11:30 PM, revealed that Resident #5 had a burn from coffee (spill) on the right front thigh. It also indicated the wound nurse had already assessed and treated the burn. A review of the wound assessment details report, dated April 17, 2025 at 10:54 AM indicated Resident #5 had a thermal burn on the right hip which was facility acquired. The same assessment also indicated the clinical stage of the wound was partial thickness. An interview was conducted on April 21, 2025 at 2:41 PM with the Activities Assistant (AA/Staff #111) who stated that she was aware of the residents' eating and drinking needs because she knows them well; and that, sometimes the CNAs will help them during activities. Staff #111 stated that sometimes they will need help with eating, but residents are able to drink their beverages on their own. When asked if Resident #5 was able to drink beverages on her own, Staff #111 indicated that she could, depending on the day because sometimes she was shaky and sometimes she can do it. Staff #111 confirmed that she was present the day of the alleged incident and shared that they were doing a morning activity and at the end of the activity they had passed out coffee to the residents. Staff #111 indicated that Resident #5 typically drinks her coffee with a straw; but, on that day the coffee had been placed in front of the resident without a straw. Staff #111 was assisting another resident before returning to Resident #5 to put a straw in her cup. Resident #5 then had asked for assistance to go to the bathroom to change her clothes. Staff #111 shared that it was then that she had seen Resident #5 with stained shorts on the right side and that she directed her co-worker to take Resident #5 to see the nurse for a skin check because the coffee was hot. An interview was conducted on April 21, 2025 at 2:54 PM with AA/Staff #140. Staff #140 stated that if a resident uses a wheelchair or if they had symptoms of Parkinson's she would know if a resident required assistance with eating or drinking beverages as well as visual observations of the residents. Staff #140 stated that she would also ask her peers and they will tell her which residents need more assistance. Staff #140 confirmed that she was present the time of the incident and recalled that Resident #5 typically would have a cup at the table and she was able to lean down and drink out of the straw. Staff #140 stated that herself and Staff #111 had their backs to Resident #5 as they were assisting another resident when Staff #140 heard Resident #5 say that she needed to go to the bathroom. Staff #140 then observed Resident #5's coffee on the table, her sweatpants, and the floor. Staff #140 took Resident #5 to the nurse to get checked out and then returned to the activity room. Staff #140 explained that when the nurses had brought Resident #5 back to the activity, some time later, she had on shorts and she had a cold washcloth on her leg. She also shared that she saw the leg was red in color. Since the incident took place, they had stopped serving coffee and were now giving the residents lemonade, because of what happened. An interview with Resident #5 was attempted on April 21, 2025 at 3:10 PM in her room, however, the resident was not interviewable. An interview was conducted on April 22, 2025 with the Activities Director (AD/Staff #46) who shared that they typically engage the nurse in a discussion about what food and beverages residents can have and then they provide the items in a safe container to the residents. Staff #46 stated that coffee services were not taking place during activities at the moment due to the recent incident and they were only doing cold beverages. Staff #46 shared that Resident #5 was to have a non-spillable cup with a straw because she is not able to pick up the cup. She has to lean over and take a sup from the straw. Staff #46 shared that Resident #5 had an open cup with a straw and had leaned over to drink from it and it spilled hot coffee which had burnt her leg. Staff #46 stated that she expected staff to watch the residents more closely and help when they are drinking from their cups; and that, the cups also needed to be further from the residents so they didn't burn themselves. Staff #46 indicated that staff did not meet her expectations in monitoring the residents, because she got burnt. If they were watching her closely, this wouldn't have happened. An interview was conducted on April 22, 2025 at 12:00 PM with the Administrator (Adm/Staff #187) who confirmed that Resident #5 had spilled coffee on herself during activities and she had injuries which the wound nurse immediately treated. Staff #187 stated that her expectation was that the kitchen staff check the temperatures of the beverages so the coffee was not hot, and that, any food that is a choking hazard is to be kept away from the residents. She also expected staff to be scanning the room and observing what is going on. Staff #187 stated that she believed staff had performed to her expectations because the coffee was not hotter than what it should have been and she thought it was unfortunate because I think she had very sensitive skin. Staff #187 also added that they are now making sure the cups have lids on them. When asked what are potential risks to the residents when not providing hot beverages to residents with no staff assistance, she indicated that there are risks of potential injury to the residents. Review of the facility policy, titled Abuse and Neglect, adopted on May 1, 2024, defines abuse as willful infliction of injury . It also defines Willfull as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It also includes physical abuse as one of the seven categories of abuse. The same policy also defines Neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that is necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on clinical record review, facility documentation, staff interviews, and review of policy, the facility failed to ensure one resident (#5) received adequate supervision to avoid a preventable elopement. Three residents were sampled. The deficient practice may increase the risk for elopement, accidents and/or injuries. Findings include: Resident #5 admitted to the facility on [DATE] with diagnoses including epilepsy, not intractable, without status epilepticus, intracranial injury with loss of consciousness status unknown and amnesia. The emergency room Report dated 02/21/23 at 10:23 p.m. included that the resident's history was obtained over the phone from the resident's family who was his legal guardian. According to the report, the resident has been battling with ongoing alcohol addiction and his elopements have been long standing but worsening this past week. She reported that the resident has been petitioned and admitted to psychiatry in the past for suicidality and depression and that she wanted to petition again for psychiatric evaluation given his ongoing reckless behavior causing a danger to himself with intermittent threats of suicidality. An Admission Summary dated 02/22/23 included that the resident arrived from the hospital at approximately 9:05 p.m. The note revealed that the resident did not have capacity and that his family was his guardian. A risk for elopement/wandering care plan initiated 02/23/23 related to a history of attempts to leave the facility unattended had a goal for the resident's safety to be maintained. Interventions included to provide structured activities including toileting and walking inside and outside. Review of an Elopement Risk assessment dated [DATE] revealed the resident had a court-appointed legal guardian, had a history of escape or elopement and had a related diagnosis. The assessment scored the resident at 8.0. Per the documentation, medium elopement risk was selected. However, according to the Elopement Risk Level, a score of 7 or above was considered high risk. A Psychosocial Evaluation conducted on 02/24/23 at 9:35 a.m. included that the resident was alert and oriented to person, place, time and situation. According to the evaluation, the resident's discharge goals included to appeal his guardianship, pass his psych test with neuro, and to discharge and find an apartment by himself. On 02/24/23 at 12:36 p.m. a Notification of Change revealed the resident was transferred from room a secured dementia unit to a secured behavioral unit for increased socialization. Review of surveillance camera footage dated 02/24/23 at 9:35 p.m. revealed images of the resident climbing out of his bedroom window and walking off the property. A nurse's note dated 02/25/23 at 5:00 a.m. included that during the writer's last round, the writer approached the resident who was covered up with a blanket. Upon touching the resident, the writer realized that it was just pillows underneath the blanket, and that the resident was not in the room. Per the note, missing person protocol was activated; the Director of Nursing (DON), supervisors, family and physician were notified. The note included that eventually a call from the family was received and per the call, the resident was with his mother. The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed no data for the brief interview for mental status. No behaviors were listed, including wandering. On 03/01/23 a written statement obtained from the Registered Nurse Unit Manager (RNUM/staff #35) included that prior to the resident's arrival at the facility, she had spoken with the nurse on the secured dementia unit to inform her of the reason why the resident was coming due to elopement from his prior facility multiple times. Per the statement, on the morning of 02/24 she informed the nurse about why he was here. Further, she stated that when she planned to move him to [the behavioral unit], she gave a report to that nurse as well. She stated that everyone was informed of his traumatic brain injury and elopement issues. On 03/22/23 at 9:36 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #31). She stated that residents would be appropriate for the behavioral unit because of their behaviors, and for their safety and the safety of others. She stated that they have had a couple of residents who have tried to leave the facility occasionally. She stated that she knew residents had eloped before, but not on her shift. In regard to resident #5, she stated that she had heard the resident had jumped out his window. At 9:49 a.m. on 03/22/23 an interview was conducted with a CNA (staff #47). She stated that she checks on the residents all shift. She stated that she had never seen anything like a written 15 minute check sheet, but that she definitely checked on them constantly. She stated that she peeks her head into the rooms now and again, even for the chill residents. She stated that she did not think that she had gone an hour or two without checking on each resident. An interview was conducted on 03/22/23 at 11:15 a.m. with the facility Administrator (staff #14). He stated that the resident was placed in the facility related to elopement from an assisted living facility and a head injury. He stated that he did not substantiate the resident leaving against medical advice as an elopement because the resident was in his right mind and alert and oriented. He stated that the term elopement was constituted by someone who does not know what they are doing. He stated that clarifying criteria was in the facility elopement policy, which he would provide. He stated that when he was notified, he called the unit managers and nurses to see if the resident was still on the premises, but because the screen from the resident's window was found on the ground outside, they figured he had left. He stated that the resident's window had actually been secured, but the resident removed the latch off the window and had taken the batteries out of the alarm. He stated that once he was aware of the event, he notified the police, family and provider. He stated that he did not inform the stated agency, and that his investigation would indicate why. He stated that on the evening of 02/25/23, the resident had told the LPN that he didn't want to be disturbed, so staff complied with the resident's request. The resident placed his pillows in his bed so it would appear like he was there, and then left through the window. He stated that later that day, he got ahold of the resident's sister. He stated that she reported that the resident had left the facility and had gone drinking. She reported that the resident had gone to his brother's house that night, but because he was drunk the family would not let him in. She stated that the resident made it to his mother's house on the reservation sometime in the afternoon of 02/26/23. He stated that the resident did not have any other medical issues that would put him at risk. He stated that the resident was placed on the secured unit for his safety. On 03/23/23 at 11:57 a.m. an interview was conducted with an LPN (staff #10). He stated that he worked the night shift on the 24th. He said he came in at 6:00 p.m. and received report. He stated that the resident had transferred to his unit that day from another unit, and that was the first time he had worked with the resident. He stated that he received a simple report on the resident. He was told that the resident liked to go outside and drink. He stated that no one told him that the resident was an elopement risk. He stated that he did not get a detailed report about why the resident was in the facility or on the unit. He stated that there were all kinds of people on the behavioral unit, residents with bipolar disorder, schizophrenia, alcohol issues - all kinds. He stated that the residents have been placed on the unit because they are not able to take care of themselves and they were placed there to keep them safe. He stated that the resident seemed really normal to him and that he didn't realize he was a resident until report. He stated that the resident did not tell him that he did not want to be disturbed that night. But, he said, it is a behavior unit so they try not to agitate the residents. He stated that the CNAs usually check the residents at night, but that sometimes he does rounds. He stated that he last saw the resident on 02/24/23 at around 9:00 p.m. when the resident walked into his room. He stated he did his rounds about 10:00 p.m. He stated that he opened the resident's door and looked in; the curtain was drawn between the beds. He stated that he did not go in, he just took a peek into the room. He stated that he could see the resident's bed and that it looked like someone was in it. He stated that he did not watch for breathing. He stated that he was the one who identified that the resident was missing around 5:30 a.m. the following morning. At 3:41 p.m. on 03/23/23 an interview was conducted with the Director of Nursing (DON/staff #22). She stated that a resident's comprehensive care plan should include things such as how to care for the resident, behaviors and major medical diagnoses. She stated that appropriate interventions to address elopement would be tailored to the individual. She stated the biggest thing would be rounds, having eyes on the resident at specific intervals, supervision and monitoring. She stated that implementation of the care plan would include monitoring every 30 minutes to 2 hours, and would be more specific to the person. She stated that the documentation would be in the CNA POC notes. She stated that her expectation was for monitoring to be care planned and followed according to the intervals in the care plan. The Safety and Supervision of Residents policy, revised July 2017, included the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The facility-oriented approach to safety addresses risks for groups of residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. Implementing interventions to reduce accident risks and hazards shall include: communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training, as necessary and ensuring that interventions are implemented. Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The Wandering and Elopement policy, revised March 2019, included the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Resident is not an elopement risk if the resident is alert and oriented and can make their own decisions. Psychological evaluation will be done to determine.

Based on observations, clinical record review and staff interviews, the facility failed to ensure that one resident (#121) with limited range of motion received the appropriate treatment and services to prevent further decrease in range of motion to the left lower extremity, and failed to ensure a physician ordered treatment for [REDACTED]. Findings include: Resident #121 was admitted to the facility on [DATE] from another facility, with [DIAGNOSES REDACTED]. Regarding the left foot: Review of the clinical record revealed a History and Physical prior to admitted d May 19, 2016, which included the resident had [MEDICAL CONDITION] right sided weakness from 2008, and bilateral lower extremities had limited range of motion (ROM) and diffuse [MEDICAL CONDITION]. The report further included the resident had right foot drop. There was no documentation that the resident had foot drop to the left foot. Review of a quarterly MDS (Minimum Data Set) assessment prior to admitted d May 21, 2017, revealed the resident required extensive assistance with bed mobility, dressing and transfers. The MDS also included that ambulation did not occur and that the resident had impairment to both lower extremities. A nursing admission evaluation dated August 23, 2017 included the resident was admitted for long term care and was alert and oriented to person, place, time, and situation. Per the documentation, the resident had a history of [REDACTED]. However, the documentation did not include the location of the contracture. The was also no documentation of any foot drop to the lower extremities. Review of the physical therapy (PT) plan of care dated August 24, 2017 revealed the resident was referred to therapy, secondary to impaired functional mobility, muscle weakness and difficulty in changing positions. Underlying impairments included hypotonic muscle tone and severely impaired gross motor coordination to the right and left lower extremity. The documentation included that the resident's lower extremities had impaired limited ROM. The documentation also included that the resident refused further skilled physical therapy. The therapy plan of care notes did not identify that the resident had a contracture/foot drop to the left foot. A review of nurse practitioner's (NP) notes dated August 24, 2017 revealed the resident had a [DIAGNOSES REDACTED]. Under the musculoskeletal/extremities section, the documentation included that the resident had a baseline ROM, with no tenderness to palpation. The documentation did not include identification of a contracture/foot drop to the left foot. A physician's note dated August 25, 2017 included a [DIAGNOSES REDACTED]. The note included there were no deformities in the resident's extremities. The documentation did not include that the resident had a contracture/foot drop to the left foot. According to the admission MDS assessment dated [DATE], the resident had a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. The MDS included the resident had [MEDICAL CONDITIONS] or [MEDICAL CONDITION], and had functional limitation in range of motion on one side to the upper and lower extremities. The MDS also identified that the resident required extensive assistance of two with dressing, bed mobility and transfers and that ambulation did not occur. Review of the resident's comprehensive care plans revealed that they did not identify that the resident had any contractures or foot drop to the left foot, nor were there any interventions to prevent a decline in range of motion. Review of the nursing notes from August 25, 2017 through October 4, 2017, revealed no evidence that the resident had a contracture or foot drop to the left foot. Further review of the clinical record revealed there was no documentation that the resident was re-evaluated by PT or that any preventative devices (such as Ankle Boot Orthosis devices or foot positioners) were put in place from August 25, 2017 through October 4, 2017 to prevent a decline in ROM to the left foot. During an observation conducted on October 3, 2017 at 11:02 a.m., resident #121 was observed lying in bed, with pillows underneath both of her legs. The resident's feet were observed to be hyperextended and the toes were pointed in a downward direction. The resident did not have any preventative devices in place to the lower extremities. In an interview with a licensed practical nurse (LPN/staff #43) conducted on October 3, 2017 at 11:03 a.m., she stated the resident does have contractures on both feet and there were no splint devices ordered or in place to prevent decline. She also said that the resident is currently not in therapy or in the RNA (restorative nursing assistance) program. Another observation was conducted on October 5, 2017 at 8:26 a.m. of the resident lying in bed, with pillows underneath both legs. The resident's feet were observed to be hyperextended and the toes were pointed in a downward direction. There were no preventative devices in place to the resident's lower extremities. An interview with the Director of Rehab (staff #147) was conducted on October 5, 2017 at 9:19 a.m. He stated that the resident previously received a physical therapy (PT) evaluation only, because the resident refused further therapy. After reviewing the PT documentation, staff #147 stated that based on the PT evaluation note, the resident had hypotonicity, but not rigidity on the left leg and there was no documentation of a contracture/foot drop identified on the left foot. An observation was conducted on October 5, 2017 at 10:41 a.m., with a LPN (staff #197). The resident was observed lying on her bed, with both legs on top of a pillow. There were no preventative devices in place to the resident's lower extremities. Immediately following the observation, staff #147 stated the resident has weakness on the left side and has foot drop on both feet. He said that he does not know when the resident developed foot drop. He stated there are no splints or boots recommended or ordered for the resident's feet. In an interview with the unit manager (licensed practical nurse/staff #116) conducted on October 5, 2017 at 11:09 a.m., she stated that both of the resident's feet look like foot drop and there are no boots in place. In a later interview this same day, staff #116 provided hospital documentation dated May 19, 2016, which showed that the resident had right foot drop. After reviewing the clinical record documentation, staff #116 stated that she could not tell if the resident was admitted to the facility with a contracture/foot drop to the left foot. Another interview with the Director of Rehab (staff #147) was conducted on October 5, 2017 at 3:58 p.m. He stated that his assessment now is that the resident has contractures on both feet. He stated that he can not tell if it is foot drop, because the resident did not want him to touch her. He stated that the contracture on the left foot must have started with foot drop, secondary to hypotonicity due to the [MEDICAL CONDITION], and in time, became a contracture. He stated this is the first time he has seen the resident and wishes that he had gotten this resident earlier, so he could have helped her condition from becoming what it is now. Regarding the left hand: The nursing admission evaluation dated August 23, 2017 included the resident was admitted for long term care and was alert and oriented to person, place, time and situation. Per the documentation, the resident was status [REDACTED]. However, the documentation did not include the location of the contracture. Review of the occupational therapy (OT) evaluation dated August 24, 2017 revealed the resident had hypertonic muscle tone and severely impaired fine and gross motor control to the left upper extremity. Per the documentation, rehab potential was poor and there was no therapy needed. A nursing note dated August 28, 2017 included the resident had a contracted left hand, which was cleansed due to a foul odor. The admission MDS assessment dated [DATE] included a BIMS score of 0, indicating the resident had severe cognitive impairment. The MDS also included the resident had functional limitation in ROM to the upper extremity. Review of the August 2017 physician's orders [REDACTED]. However, this order was not transcribed onto the August and September 2017 Medication Administration Records (MAR), Treatment Administration Record (TAR) or the monitor sheets. Review of the clinical record revealed no evidence that this order was consistently implemented, as ordered by the physician. A comprehensive care plan included the resident had a contracture to the left hand. An intervention included for the application of a therapy carrot to the left hand as tolerated. In an interview with a licensed practical nurse (staff #43) conducted on October 3, 2017 at 11:03 a.m., she stated that the resident has a contracture to the left hand and there was no splint device ordered or in place. During an interview with the Director of Rehab (staff #147) conducted on October 5, 2017 at 9:19 a.m., he stated the resident received an occupational therapy (OT) evaluation only, as the resident's functional level was the same as her prior level, so no further therapy was needed. He stated the resident has limitations to her left hand and therapy tried to put a rolled washcloth or carrot splint in her left hand, but the resident would take it off. An interview with a LPN (staff #197) was conducted on October 5, 2017 at 10:41 a.m. He stated the resident has some contractures to the fingers of the left hand and has a carrot splint for this. An observation of the resident with staff #197 was conducted immediately following the interview. The resident was observed lying on her bed, with her left arm on top of a pillow. The fingers of the left hand were contracted and there was no carrot splint in place. At this time, staff #197 stated that the carrot splint was not in the resident's hand and he did not know why it was not in place. He further stated that the carrot splint must be placed in the resident's left hand every time the resident is awake. During an interview with the unit manager (staff #116) conducted on October 5, 2017 at 11:09 a.m., she stated that if there is an order for [REDACTED]. An interview with the Director of Nursing (DON/staff #55) was conducted on October 5, 2017 at 1:13 p.m. She stated that if the boxes in the MAR, TAR or the monitor sheets are blank and not initialed, it means the treatment was not documented as being administered. An interview was conducted on October 5, 2017 at 5:20 p.m., with the administrator (staff #10), the corporate Director of Social Services, and activity (staff #203) staff. Staff #203 stated that the facility does not have a policy regarding contractures. In a later interview with staff #203 on October 5, 2017 at approximately 6:00 p.m., she stated the facility does not have a policy regarding limited range of motion or rehabilitation.

Based on clinical record review, hospital record review, staff interviews, and review of facility policy and documentation, the facility failed to ensure that one resident (#6) was administered the correct dose of [MEDICATION NAME] sulfate, resulting in a significant medication error and intensive care unit hospitalization . Findings include: Resident #6 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the controlled drug record for another resident documented that the other resident was to take 0.25 milliliters (ml) equivalent to 5 mg of [MEDICATION NAME] solution by mouth/under tongue every two hours as needed (PRN) for pain and shortness of breath (SOB). For the December 29, 2011, narcotic count on the evening shift the bottle contained 25.75mL of [MEDICATION NAME]. On the morning of December 30, 2011, the bottle contained 2mL of [MEDICATION NAME]. A review of facility documentation from December 30, 2011, revealed that Staff #1 administered [MEDICATION NAME] 15mL equivalent to 300mg to resident #6 instead of the resident's ordered [MEDICATION NAME] 15mg. This 300 mg of [MEDICATION NAME] was fast acting and 20 times the physician ordered 15 mg extended release [MEDICATION NAME] the physician had ordered for resident #6. The [MEDICATION NAME] solution that Staff #1 administered to the resident belonged to another resident. It was not until the narcotic count at shift change that the medication error was noticed when Staff #1 admitted to giving the resident 15mL/300mg of [MEDICATION NAME] that belonged to another resident. A review of the nursing notes from December 30, 2011, documented that at the beginning of the morning shift the resident had an oxygen saturation level of 80 percent, respirations were labored, the resident was lethargic, not responding to verbal cues, and vomiting. A review of the physician's orders [REDACTED]. A review of hospital records revealed that the resident was started on a [MEDICATION NAME] drip of 0.3mg/hour continuous and was admitted to the Intensive Care Unit for further treatment. During an interview conducted on January 26, 2012 at 1:10pm, Staff #1 stated that she did give the resident liquid [MEDICATION NAME] instead of the pill form. She was unable to give an explanation as to why she gave the liquid instead of the pill, and further stated that she was having a bad day, and had issues with the computer. Review of the facility's policy on Medication Administration documented that staff members are to remember the 5 R's when administering medications, which are right patient, right drug, right route, right dose, and right time.

Based on observations, clinical record reviews, staff interviews, and review of facility policies and procedures, the facility failed to provide adequate supervision and assistance devices to prevent falls for three residents (#s 16, 137, and 23). Two residents sustained actual harm (#s 16 and 137). The sample size was seven. Findings include: -Resident #16 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a care plan dated July 22, 2011, which documented "Alteration in ADL (activities of daily living) related to history of CVA (cerebral vascular accident), mobility, transfer" as a problem. Approaches documented were to "Provide assistance with ADLs as needed every day...Provide assistance during transfers as needed." The resident's clinical record revealed a quarterly MDS (Minimum Data Set) assessment dated [DATE], documented that the resident required a two person physical assist for transfers. The resident's clinical record revealed a Fall Risk assessment dated [DATE], documented that the resident's fall risk score was a 10 or high risk. A review of a certified nursing assistant (CNA) Communication Tool, undated, revealed that two people should assist the resident with transfers. A review of facility documentation revealed a Resident Incident Report dated August 27, 2011, that documented "...reported to me that patient was on the floor and she needed assist...As I entered shower room I observed patient on floor and lying on her back...explained that while trying to move patient from toilet to wheelchair using the lift patient could no longer assist and patient's legs gave out and patient started to slip...stated she guided her to the floor...injury to upper left shoulder abrasion approximately 6 inches in length by 1.5 inches wide, abrasion to spine, area approximately 9 inches long and 1.5 inches wide...xrays ordered and done..." The resident's clinical record revealed Departmental Notes dated August 28, 2011, which documented "Late entry of 08/27/11...patient complains of pain to right elbow and right knee tenderness of right shoulder when touched. Physician notified and xray of right shoulder and left hand ordered. Xrays results indicate acute humeral neck fracture noted with impaction. Physician notified of results. New orders received to sent patient to ER for orthopedic stabilization." A review of hospital documentation dated August 28, 2011, revealed an xray report which documented "...There is a right humeral neck fracture..." A review of facility documentation revealed a Final Report Regarding Resident Injury dated August 30, 2011, which documented "I used the lift to transfer...from the wheelchair to the toilet in the shower room. I did not have anybody help me use the lift...'I didn't ask because I couldn't find them (the other CNAs on the unit)'...When (CNA) was asked why she used the assistive lift versus the passive lift...stated we use the assistive lift because she can help us by using her upper body strength." An interview was conducted with the staff development coordinator on October 5, 2011. The staff development coordinator stated that at least two people should be used when transferring a resident with a mechanical lift. An interview was conducted with the ADON (assistant director of nursing) on October 5, 2011. The ADON stated that the resident should have been transferred with a passive lift and that all residents should be transferred with the assistance of two people. The ADON further stated that the resident was not transferred as she should have been. An interview was conducted on October 6, 2011, with the CNA who transferred the resident on August 27, 2011. The CNA stated that she used the assist lift to transfer the resident from the toilet to her wheelchair and the resident stated "I can't hold it, I can't hold it." The CNA stated that she lowered the resident to the floor and called for help. The CNA stated she should have sought the assistance of another staff member for the transfer but no one was in the hall. The CNA stated "It's my fault, I know." When asked why she used the assist lift rather than the passive lift the CNA stated that she saw everybody else use the assist lift for the resident. The CNA stated that the type of lift that was to be used for the resident was written outside of each resident's door but that she did not check to see what type of lift was to be used for this resident. A review of the facility's policy "No Lift Safe Patient Handling" documented "minimum of 2 caregivers." -Resident #137 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of resident's medical record revealed a fall on January 17, 2011, in which the resident sustained [REDACTED]. The resident's care plan was updated on January 18, 2011, and stated the resident was to wear Geri-Sleeves, have bed and chair alarms placed and an order for [REDACTED]. The clinical record documented that the resident was found lying on the floor in the hallway by a visitor on January 21, 2011. The resident's care plan was updated on January 26, 2011, to continue with bed and chair alarms and to educate the staff to ensure the alarms were on and were functioning at all times. It further stated the resident would be educated not to turn off the alarms and the resident was to be screened by rehab. The clinical record documented that the resident slid off her wheelchair as she attempted to stand on January 30, 2011, this was witnessed by a CNA. The resident care plan was updated to include that the resident would be provided with non-skid socks. The resident was noted to have a fall on April 7, 2011, as reported by the interdisciplinary team (IDT) on May 5, 2011. No further assessment or care plan changes were documented after this fall. The IDT met on April 18, 2011, and reviewed the resident's fall history. They determined that the resident would continue with bed and chair alarms, staff were to ensure that alarms were in place and were functioning. The resident was to be educated to call for assistance. It was on this same date that a member of the IDT went to verify the alarms were in place and were functioning and found that the alarms were not in place. The IDT team member was told by the staff that the resident refused the alarms, that she would turn the alarms off, and that the resident had removed her alarms and would "Toss them somewhere" else. On April 20, 2011, the care plan was updated to include that the resident refused to have alarms in place. A review of the annual MDS assessment dated [DATE], reported that the resident was independent with her bed mobility, ability to transfer herself and walk in her room. The resident was recorded to have unsteady balance but was able to steady herself without human assistance and restraints were not used for this resident. The resident fell again on May 18, 2011. The resident's care plan was updated on May 20, 2011, and stated "Fall on 5/18/11 Res. to sign risk vs. benefit." Further review of the medical record revealed a fall on May 24, 2011, in which the resident sustained [REDACTED]. The care plan was updated on May 26, 2011, to include that occupational therapy (OT) was to screen the resident. The IDT team met on May 26, 2011, and decided to have the resident sign a risk verses benefits form. The risk verses benefits form was reviewed. It included an area of concern as increased falls, benefit of increased safety and risk of possible injury that may require treatment and/or hospitalization . The resident refused to sign the form. The IDT completed a quality indicator screening form on May 27, 2011, which indicated that the resident had fallen secondary to reaching, it was noted that the linen cart fell on the resident, the resident was to be screened for OT and physical therapy (PT) needs. It further reported that this was not an isolated fall. The resident was noted to have a decrease in function and it was recommended to conduct an OT/PT evaluation. An MDS change in condition assessment dated [DATE], revealed that the resident required extensive assistance of one staff member to move around in her bed, to transfer herself and she no longer was able to walk in her room. The medical record revealed the resident fell on [DATE], and did not sustain any injury. The resident stated she was standing and the wheelchair slid away from her. The IDT team met to review her fall and stated that an alarm should be placed in a location where the resident could not turn it off. The medical record revealed that the resident fell on [DATE]. The resident was not injured. There were no further interventions added to the resident's care plan. The medical record revealed that the resident fell on [DATE]. There were no further interventions added to the resident's care plan. The medical record revealed that the resident fell on [DATE]. Review of the resident's care plan indicated that no further interventions were added. The medical record revealed that the resident fell again on August 13, 2011. The resident was found on the floor in her room and stated she had turned off her chair alarm and did not know how she had fallen. The IDT reviewed the resident's falls on August 15, 2011, and stated that PT was to evaluate the resident. A physician's order dated August 15, 2011 stated PT to evaluate. A physician's order dated August 16, 2011 stated PT clarification: Skilled PT daily five times a week for five weeks for gait difficulty - trial and application of proper restraint. This was 81 days after IDT had initially recommended a PT evaluation. The care plan was updated on August 16, 2011, and stated "Fall on 8/11/11 and 8/13/11 X 3." PT to evaluate and treat. A review of the PT note on August 16, 2011, stated that the resident was not able to adapt to the restraints, i.e., the pommel cushion or the Merry Walker. The resident fell on [DATE]. The resident's care plan stated "Fall on 8/17/11" continue with PT caseload. The resident fell on [DATE]. Review of the medical record revealed an IDT review dated August 18, 2011, which stated that PT was to trial the resident with a seat belt and Merry Walker. The resident's care plan dated August 19, 2011 stated "Fall on 8/18/11. NAI. PT to trial resident with seatbelt and Merry Walker." Review of PT notes for the week of August 16 through August 22, 2011, revealed that the resident had failed on Merry Walker, the resident was able to release the gait belt and it did not prevent her from standing, the resident was able to tolerate a lap buddy. The PT recommended a lap buddy to prevent the resident from falls. Review of the medical record revealed a physician's order dated August 24, 2011, which stated lap buddy while in wheelchair due to poor safety awareness. The resident's clinical record revealed a falls care plan updated July 26, 2011, which documented "Continue with alarms and fall precautions." A review of the resident's significant change in status MDS assessment dated [DATE], revealed the resident required a one person physical assist with transfers and had two or more falls since the prior MDS assessment. A review of a CNA Communication Tool, undated, revealed the resident was to have bed and chair alarms. Facility documentation dated September 4, 2011, revealed a Resident Incident Report which documented "CNA heard some movement in resident room. Found resident sitting on floor next to bed...Left hand, wrist slightly tender. Left hip slightly tender." There was no documentation on the Resident Incident Report to indicate if bed and chair alarms were being used and whether or not the alarms activated before the resident fell . The resident's clinical record revealed Departmental Notes dated September 5, 2011, which documented "3-11 shift noted at end of their shift resident to have swelling on left hip and some bruising on left hand wrist...Hospice to assess for xrays or transfer to hospital in a.m." A review of hospital documentation dated September 6, 2011, documented "Differential diagnoses, hip fracture, hip dislocation, spinal fracture, closed head injury...wrist fracture, contusions." The resident was observed on October 5, 2011 at 10:55 a.m. she was seated with a lap buddy in her wheelchair, but there was no alarm attached to her wheelchair. An interview was conducted with the social worker on October 5, 2011. The social worker stated that when she completed the facility's investigative report, interviews of staff only revealed that they heard a noise in the resident's room. The social worker stated the investigative report did not mention if the alarm sounded when the resident fell . The social worker further stated that she did not know if the alarm was on or off when the resident fell . An interview was conducted with the ADON on October 5, 2011. The ADON stated that the Resident Incident Report should have indicated whether or not an alarm was on when the resident fell and whether or not it sounded. The ADON further stated that without the documentation, she would be unable to determine whether or not the alarm was on when the resident fell . An interview was conducted with a CNA on October 6, 2011, who stated the resident still can find and disable her alarms. Review of the facility policy and procedure on the prevention and minimization of serious accidents stated "The facility must ensure that the resident's environment remains as free from accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent/minimize serious accidents." It further stated "...In all situations, the facility's responsibility to accommodate individual needs and preferences and abide by the resident's right to choice and self-determination must be balanced against the need to prevent/minimize serious resident accidents..." A review of the facility's policy "Fall Prevention Program" documented that "The Director of Nursing/designee will be responsible for ensuring that residents who have been identified at higher risk or who have experienced a recent fall have recommended interventions in place..." -Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The nurse's admission assessment note dated May 13, 2011, stated that the resident required one to one because of his risk of falls. The resident also required an alarm to his bed and a mat on the floor, the note further stated that the resident was confused. The resident's care plan dated December 30, 1899 (sic) for falls was reviewed related to the resident's fall risk. It stated that the resident had impaired vision and needed glasses and that he had impaired mobility and required a wheelchair. The resident goals on the fall care plan included to maintain a safe environment through the next review. There was no date specified for the next review. There was no evidence identified to indicate that the resident's progress toward his goals had been reviewed or that the care plan had been updated. Further review of the resident's care plans revealed an undated care plan which reported a potential for fall/entrapment/other injury. The undated goal indicated the resident would have no falls or episodes of entrapment. The approaches listed included to assist the resident with transfers and activities of daily living as needed. To ensure the call light was within reach. To implement the falling star as needed and to ensure the foot path was clear of clutter and that adequate lighting was provided in the resident's room. Review of the nursing notes revealed that on May 16, 2011, the resident fell . The resident was found on the floor. The resident had stated he was trying to tie his shoes because he wanted to go out to the bus stop as he wanted to leave the facility. Staff assessed him to have no injuries and he was placed in a wheelchair in the hallway for observation throughout the shift due to his risk for falls. The IDT reviewed the fall on May 19, 2011, and stated that the resident was to have bed and chair alarms in place and functioning and the resident's bed was to be kept in the lowest position. The care plan was not updated. On May 25, 2011, the nurse's note stated that the resident had poor safety awareness and needed frequent supervision. The care plan was not updated after the IDT meeting with new interventions or approaches to reduce the resident from falling. Review of the nurse's note dated June 13, 2011, revealed that a wander guard was placed on the resident's right wrist as the resident would not stay in his wheelchair and would ambulate outside and was not easily re-directed. The medical recorded documented that on June 16, 2011, the resident was found sitting on the floor by the bathroom with a laceration to his nose and a possible fracture. The resident denied hitting his nose. It further documented that 911 was called to have the resident evaluated at the emergency room due to his history. There was evidence on the resident's care plan that he was to have a rehabilitation screen. There were no additional interventions goals or review dates were indicated. Review of the medical record revealed the resident fell on [DATE], and was found sitting upright in his room doorway with his right leg extended and his left leg bent inwards with a large amount of stool on the floor. The resident was not injured and stated he just liked to sit on the ground. The nurse's notes dated August 14, 2011, reported that the resident was found on the ground. The resident had stated he sat down on the ground because he was tired. There were no injuries recorded. There was no evidence that the care plan was updated to include any new interventions. The IDT team met to discuss his fall and decided to have the resident sign a risk versus benefits form related to the dangers of sitting on the ground. This was verbally approved by his Power of Attorney (POA) on August 19, 2011. The medical record indicated that the resident fell again on October 4, 2011. No injuries were sustained and there was no evidence that the care plan was updated to include any new interventions. An observation of the resident was made on October 5, 2011 at 2:00 p.m. he was noted to be lying in his bed. An interview was conducted with the licensed practical nursing (LPN) and the unit manager on October 5, 2011 at 2:30 p.m. The licensed staff stated that no date was present for any of the resident goals and that there was no revision to the care plan after any of his three falls. Review of the facilities policy on the fall prevention program revealed that the "Purpose...To gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs. To ensure consistency in the implementation of preventive measures to assist with reduction of falls. To evaluate outcomes."